TEXT-BOOK 


OF 


PSYCHIATEY 

A  Psychological  Study  of  Insanity 

FOR  PRACTITIONERS  AND  STUDENTS 


DR.  E.  MENDEL 

A.  O.  PROFESSOR  IN  TH^/UNIVERSITY  OF  BERLIN. 


AUTHORIZED  TRANSLATION 

EDITED  AND   ENLARGED   BY 

WILLIAM  C.  KRAUSS,  M.D. 

Buffalo,  N.  Y. 

President  Board  of  Managers,  Buffalo  State  Hospital  for  Insane  ;  Medical  Superintendent 

Providence  Retreat  for  Insane;  Neurologist  to  Buffalo  General,  Erie 

County,  German,  Emergency  Hospitals,  etc.  ;  Member  of 

the  American  Neurological  Association. 


PHILADELPHIA 

F.  A.   DAVIS  COMPANY,   Publishers 
1908 


n  ,  2 


COPYRIGHT,  1907, 

BY 
F.  A.  DAVIS  COMPANY. 

[Registered  at  Stationers'  Hall,  London,  Eng.] 


Philadelphia.  Pa.,  U.  S.  A. 

Press  of  F.  A.  Davis  Company, 

igi4-i6  Cherry  Street 


PREFACE. 

The  addition  of  the  jasychiatric  clinic  to  those  clinics  at 
which  the  attendance  of  medical  students  is  obligatory,  and  the 
addition  of  psychiatry  to  the  list  of  subjects  in  respect  to  which 
physicians  must  be  examined  in  conformity  with  the  ordinance 
concerning  examinations  of  May  28th,  1901,  have  prompted  the 
puhlication  of  this  text-book. 

There  is  no  lack  in  Germany  of  excellent  works  on  psychia- 
try, but  they  have  been  deemed  too  comprehensive  for  the  student 
attending  clinics  and  for  the  young  physician  who  is  subject  to 
examination. 

The  author's  object  is  to  bring  cases  demonstrated  at  the 
clinic  into  the  general  perspective  of  psychiatry,  and  to  enable 
the  student  to  fill  uj)  the  gaps  which  the  clinic  must  necessarily 
omit  in  the  limited  time  given. 

It  is  readily  understood  that  in  this  volume  clinical  histories 
could  not  be  included.  It  is  especially  true  of  psychic  diseases, 
as  well  as  of  ailments  included  in  the  general  study  of  medicine, 
that  clinical  histories  do  not  give  an  actual  picture  of  the  dis- 
ease to  him  who  would  learn  to  know  it.  Clinical  instruction 
alone  can  teach  this. 

Extended  notes  from  medical  literature  do  not  properly 
pertain  to  a  text-book.  It  does  not  seem  out  of  place,  however, 
to  refer  to  monographs,  and  especially  to  recently  published 
works,  in  which  have  been  collected  the  literature  of  striking 
special  conditions,  thus  offering  the  reader  an  opportunity  to 
instruct  himself  still  further  in  any  special  question  and  without 
particular  trouble. 

An  experience  of  thirty  years  in  teaching  psychiatry  has  con- 
vinced the  writer  of  the  practical  usefulness  of  arrangement  and 
classification,  especially  of  the  divisions  of  the  psychoses. 

(iii) 


iv  Preface. 

Although  the  author's  division  of  the  ps}X'hoses  may  not  be 
wholly  free  from  objection,  and,  like  all  other  groupings  of  the 
psychoses  heretofore  made,  may  lack  a  characteristic  or  unique 
principle  of  classification,  it  will,  if  followed,  enable  the  physi- 
cian to  make  a  diagnosis  in  the  great  majority  of  cases,  and  thus 
to  gain  more  extended  understanding  of  the  clinical  significance 
of  isolated  cases  will  not  be  difficult. 
Beblin. 


TRANSLATOR'S  PREFACE. 


No  apology  is  necessary  for  the  appearance  in  English  of 
Professor  Mendel's  work  on  Insanity.  For  many  years  the 
author  has  been  in  the  front  rank  of  German  men  of  science,  and 
his  investigations  in  nervous  and  mental  phenomena  have  added 
vastly  important  data  to  these  complex  studies. 

It  is  especially  in  Psychiatry  that  he  has  won  enduring 
honors,  and  in  consequence  was  selected  to  assist  in  the  revision 
of  those  sections  of  the  Prussian  code  of  criminal  procedure 
relating  to  the  insane. 

For  many  years  visitors  to  his  clinic  and  polyclinic  have 
been  impressed  by  his  general  courtesy  and  open  hospitality  to 
'^Amerikaner,"  and  in  consequence  many  warm  friendships  have 
been  engendered. 

This  work,  the  result  of  a  lifetime  of  observation,  bears  the 
stamp  of  thoroughness  and  scientific  acumen  and  may  well  be 
called  "A  Psychological  Study  of  Insanity."  Some  license  has 
naturally  been  taken  in  the  translation,  but  it  has  been  with  the 
thought  uppermost  of  rendering  faithfully  Professor  Mendel's 
lucidity  of  style,  while  adapting  it  to  the  rules  of  English  con- 
struction. The  expression  "twilight  states"  has  been  adopted 
as  a  literal  translation  of  "dammerungs-zustande,"  instead  of 
the  usual  designation,  "sub-consciousness  states."  "Zwangs 
vorstellungen"  has  been  rendered  as  "imperative  concepts"  rather 
than  l)y  the  word  "obsessions."  Otherwise  the  editor  has  tried 
to  make  as  literal  a  translation  as  possible ;  has  omitted  the  Prus- 
sian procedures  relating  to  the  insane,  and  substituted  the  New 
York  State  laws  and  commitment  form.  The  chapters  on  De- 
generacy and  Heredity  have  been  materially  enlarged,  and  ad- 
ditions have  been  made  throughout  the  work. 

Buffalo,  N.  Y.,  January,  1907. 

(V) 


Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofpsychiOOmend 


CONTENTS. 


PAGE 

Author's  Preface   iii 

Translator's  Preface v 

Introduction   1 


Part  I.    GENEEAL  PSYCHIATEY. 
A.     General  Symptomatology. 

I.  The  Disturbances  of  Sensation  and  Sense-perception 7 

1.  Hyperesthesias   and  Paresthesias   Originating  in   Disease  of 

the  Superiicial  Terminal  Apparatus,  and  of  the  Sensory 

Conductors    7 

2.  Hyperesthesias   of   the   Sensory   Centers   of   the   Cortex   and 

Their  Paths  of  Association 8 

3.  Hallucinations  or  Sensory  Deceptions 10 

4.  Hypesthesia  and  Anesthesia  of  the  Sense  Perception 24 

IT.  The  Disturbances  of  Thought 25 

1.  Imperative  Concepts    26 

2.  Pathological  Heightening  of  the  Rapidity  of  Associations.  .  .  26 

3.  Delusions    ' 27 

{ a )    Expansive  Delusions 27 

( b  )    Depressive  Delusions    28 

(d)    Paranoic  Delusions  of  Persecution 30 

Jealous  Delusion.     Querulous  Delusion 31 

(d)    Delusions  of  Negation 32 

Delirium  INIetabolicum   33 

Delirium  Palingnosticum 33 

Diagnosis  of  Delusions 36 

Prognosis  and  Treatment 38 

4.  Pathological   Weakness   in   the   Rapidity   and  Power   of   the 

Associations    39 

III.  The  Disturbances  of  Reproduction.     Memory 40 

1.  Pathological     Heightening     of     the     Faculty     of     Memory. 

Ilypermnesia   40 

2.  Falsification  of  the  Image  of  Memory.     Paramnesia 41 

3.  Pathological   Diminution   and   Destruction   of   the   Power  of 

]\Iemorj'.     Amnesia    43 

IV.  The  Disturbances  of  the  Feelings 45 

1.  Disturbances  of  the  Sensory  Feelings 45 

(a)  Pathological  Heightening    45 

(b)  Pathological  Diminution  or  Destruction 48 

(c)  Pathological  Inversion  of  the  Feelings 48 

Feeling  of  Disease  50 

2.  Disturbances  of  the  Feelings  of  Judgment 51 

(o )    Pathological  Heightening   51 

(6)    Pathological  Diminution  51 

(c)    Pathological  Inversion  52 

Moral  Insanity 53 

(vii) 


viii  Contents. 

PAGE 

V.  The  Distiiiltances  in  the  Condition  of  the  Mind 54 

Frame  of  the  Mind.     Emotions 55 

Anxiety    55 

Phobias    56 

Mania  of  Doubt  with  Fear  of  Touch 57 

^'I.  Tiie  Disturbances  of  Consciousness 59 

Circumspection.      Confusion    59 

Observation   59 

Sleep.     Narcolepsia.     Sleep  Intoxication 61 

1.  Twilight  States 62 

2.  Stupor 6.3 

Raving    68 

\U.  The  Disturbances  of  Self-consciousness 69 

VIII.  The  Disturbances  of  Action 70 

1.  Reflex  Actions • 70 

2.  The  So-called  Arbitrary  Actions 72 

(a)   Pathological  Heightening  of  the  Activity 72 

(6)    Pathological  Diminution  of  the  Activity 73 

(c)    Qualitative  Changes  of  the  Activity 74 

IX.  The   Disturbances  of   Speech,   Writing,   and  the  Expression   of 

the  Countenance , 77 

1.  Lack  of  Speech 77 

]\lutacism.     jMutism 77 

Deaf-mutism.     Motor  Aphasia.     Anarthria 78 

2.  Change  of  the  Speech 78 

(a)    Bj^  the  Morbid  Disturbance  of  the  Ideas 78 

(6)    By  Pathological   Disturbance  in   the  Ideas   Connected 
with    Irritation   or    Paralytic   Phenomena   in    the 

Cortical  Speech  Center 79 

Mechanical  Repetition   of   Words   or  Phrases.     Per- 
severation      79 

(r)    By  Pathological  Processes  in  the  Speech  Center 79 

Word-deafness    SO 

{(I)    In  the  Unnatural  Course  of  Speech 80 

(e)    In   the   Change  of   tlie   Grammatical    Construction   of 

Sentences   SO 

{f)    Stuttering  and  Stammering 80 

{g)   Tone  of  the  Voice 81 

3.  Change  of  the  Writing 81 

4.  Change  of  the  Expression  of  the  Countenance 83 

X.  The  Pathological  Disturbances  in  the  Condition  of  the  Body.  ...  84 

1.  The  Cranium  and  th.e  So-called  Signs  of  Physical  Degener- 

ation   ' 85 

Measurements  of  the  Cranium 85 

Ear   93 

.    Eye   94 

Hard  Palate   97 

Teeth    98 

Skin    99 

Genital  Apparatus 99 

2.  The  Disturbances  of  the  Peripheral  Sensorial  Apparatus.  .  .  .  99 

The  Eye   99 

3.  Disturbances  of  the  Sensibility loi 


PAGK 

4.  Disturbances  of  the  Motility 102 

Enuresis.     Ischuria  lO.'J 

Discharge  of  tlie  FiEces 104 

5.  Disturbances  of  the  llcflexes 104 

Tendon  llefiexes   104 

Skin    105 

INIucous  Membrane — Visceral   Reflexes 100 

6.  Disturbances  of   the  Vasomotor   Nerves.     Anomalies   of   the 

Secretions.     Trophic  Disturbances 100 

Precordial  Anxiety   100 

Excretion  of  Saliva.     Sweat  Secretion 100 

Decubitus.     Othematoma   107 

XI.  Anomalies  of  the  Internal  Organs 101) 

Lungs   109 

Vascular  System   109 

Digestive  Apjsaratus.     Sitophobia   110 

Urine    Ill 

Menstruation.     Bodily  Temperature.     Weight  of  the  Body..  112 

B.     The  Etiology  of  Mental  Diseases. 

Statistics   113 

I.  Predisposing  Factors   115 

Hereditary  Foundation 115 

Heredity  Transferred  in  the  Germ 116 

Uterine  Heredity   119 

II.  The  Factors  Favoring  the  Breaking  Out  of  the  Disease  when  the 

Predisposition  is  Present 122 

1.  Puberty.     Hebephrenia    122 

Katatonia    123 

Dementia  Prsecox 124 

2.  Climacteric 125 

3.  Old  Age 125 

4.  Pregnancy 126 

5.  Parturition    126 

6.  Puerperium    126 

7.  The  Period  of  Lactation 127 

III.  Direct  Causes 128 

1.  Psychic 128 

Induced  Insanity.     Twin  Insanity.     Transformed  Insanity.  129 

2.  Somatic  Causes   129 

3.  Mixed  Causes 131 

C.     Outbreak,  Course,  Duration,  Result  of  Psychoses. 

Outbreak,  Course,  Duration,  Result  of  Psychoses 133 

1 .  Transitory  Mental   Disturbances 133 

2.  Acute,  Mental  Disturbances 134 

3.  Chronic  Mental  Disturbances 130 

4.  Periodically  Progressive  Mental  Diseases 130 

Results  of  the  Psychoses 138 

1.  Recovery   138 

2.  Incomplete  Recovery 138 

3.  Incurability   139 

4.  Death    141 

5.  Suicide 141 


X  Contents. 

D.     Pathological  Anatomy  of  Mental  Diseases.  page 

Pathological  Anatomy  of  Mental  Diseases 144 

E.     Diagnosis  or  Mental  Diseases. 

Diagnosis  of  Mental  Diseases 145 

Simulation.     Dissimulation 146 

F.     Prognosis  of  Mental  Diseases. 

Prognosis  of  Mentiil  Diseases 149 

G.     General  Treatment. 

(Jeneial  Treatment    150 

Commitment  to  an  Institution 151 

Causal  Indication    153 

Symptomatic  Treatment 154 

Paut  J  I.     SPECIAL  PSYCHIATPiY. 

Special  Psychiatiy   160 

T.  Idiotism    161 

1.  Imbecility 161 

Special  Symptomatology 162 

1.  Power  of  Reproduction — Memorv 162 

2.  Thought    ■ 163 

3.  Anomalies  of  the  leclings 164 

4.  Action  165 

2.  Idiocy    167 

( a )  Congenital  Form  167 

( b )  Acquired  Form 167 

Special  Symptomatology' 168 

1.  Sense  Perceptions 168 

2.  Power  of  Reproduction — IMemorv 168 

3.  Thought    ' 168 

4.  Feelings    169 

5.  Speech   169 

6.  The  Physical  Condition 169 

Paralytico-epileptic  Idiotism 170 

7.  Sensory  Organs  and  Cutaneous  Sensations 170 

Etiology   171 

Pathological  Anatomy 172 

Course    173 

Diagnosis 173 

Prognosis   174 

Treatment   174 

II.  Functional  Psychoses 175 

1.  Delirium  Hallucinatorium    175 

(a)  Active  Delirium  Hallucinatorium 175 

(b)  Passive  Dolirium  Hallucinatorium 175 

(c)  Interchange  of  the  S^nnptoms  of  Both  Forms 176 

Special  Symptomatology- 176 

Etiology 177 

Outbreak    177 

Duration    178 

Results , 178 

Diagnosis 178 

Treatment   179 


Cuntents.  xi 

PAGE 

2.  Mania   180 

Tjpical  Mania   180 

llypomania    182 

llecunent  Mania   182 

Mania  Gravis   182 

Periodical  Mania  182 

Special  Symptomatology 183 

Etiology-   184 

Outbreak    185 

Course    185 

Duration    185 

Results 185 

Diagnosis 185 

Prognosis  18ti 

Treatment   186 

3.  Melancholia    187 

(a)  Simple  Melancholia 187 

( b )  Typical  IMelancholia   188 

1.  Hypochondric  Melancholia   188 

2.  Moral  Melancholia   188 

3.  General  Melancholia 189 

Special  Symptomatology 190 

Etiology 193 

Outbreak 193 

Course 193 

Periodic  Melancholia 193 

Remittent  Melancholia   193 

Duration    193 

Results   194 

Diagnosis  194 

Prognosis 194 

Treatment   195 

4.  Circular  Psychosis   196 

5.  Paranoia  199 

(a)  Rudimentary  Paranoia.     Imperative  Concepts 199 

( b )  Typical  Paranoia 203 

1.  Acute  Simple  Paranoia 203 

2.  Chronic  Simple  Paranoia   (combined) 204 

3.  Acute  Hallucinatory  Paranoia 205 

4.  Chronic  Hallucinatory  Paranoia 206 

Varieties    206 

1.  Hypochondric  Paranoia  206 

2.  Primitive  Paranoia 206 

3.  Paranoid  Melancholia 207 

4.  Paranoid  Dementia •.  .  .   207 

5.  Katatonic  Paranoia   207 

6.  Periodical  Paranoia   207 

Special  Symptomatology    207 

Etiology   207 

Diagnosis 210 

Treatment   211 

6.  Acute  Dementia 211 

Pathological  Anatomy  of  the  Functional  Psychoses 213 


xii  Contents. 

PAGE 

HI.  The  Psychoses  Arising  from  Central  Neuroses 213 

1,  The  Epileptic  Psyciioses   213 

(a)    Pre-epileptic  Insanity 214 

(6)    Post-epileptic  Insanity 214 

(c)  Epileptic  Equivalents  215 

Special  Svniptomatologv 215 

Etiology'  \ " 216 

Diagnosis 216 

Treatment   216 

(d)  Chronic  Epileptic  Psychoses 217 

•     2.  The  Hysteric  Psychoses ". 219 

(a)   Pre-  and  Post-hysteric  and  Equivalents 219 

(h)    Subacute  and  Chronic  Psychoses .  219 

(c)    Complication  of  a  Psychosis  with  Hysteria 219 

Special  Svmptomatology 221 

Etiology  ' .' 222 

Diagnosis 222 

Treatment 223 

3.  The  Choreic  Psvclioses   224 

(o)   The  Chorea  of  Sj'denhaiii 224 

(6)    Chronic  Progressive  Chorea 224 

IV.  The  Psychoses  of  Intoxication 225 

1.  Auto-intoxication  Psychoses.     Endogenous  Psychoses 225 

A.     Psychoses  Due  to  Functional  Disturbance  of  the  Thyroid  Glands  225 

(a)  Infantile  Myxedema.     Sporadic  Cretinism 225 

( b )  Myxedema  of  Adults 227 

(c)  Cretinism 227 

(d)  Psychoses  with  Basedow's  Disease 229 

(e)  Psj'choses    which    come    from    the   Intestine   or    from 

Other  Organs  by  Auto-intoxication 230 

2.  Psychoses  which   are  Called  Forth  by  a  Poison  Introduced 

Into  the  Body  from  Without   (Exogenous  Psychoses  I  ....  231 
(a)    Psvchoses  bv  Infectious  Diseases.     Psvchoses  of  Infec- 

'  tion  .  .  .' \ 231 

Delirium  of  Fever. . 231 

Inlluenza,  Typhus,  etc 232 

Korsakoff's  Psychosis   232 

(6)    Ergotism 233 

(c)    Pellagra 234 

3.  Psychoses  which  are  Evoked  by  Organic  Poisons 234 

(a)   Alcoholic  Psychoses 234 

1.  Acute  Alcoholic  Psychoses 235 

2.  Subacute  Alcoholic  Psychoses 236 

Delirium  Tremens   236 

Varieties    236 

(a)   Abortive  Delirium  Tremens 236 

(6)    Chronic  Delirium  Tremens 237 

(c)    Febrile  Delirium  Tremens 237 

(f/)   Polyneuritic  Delirium  Tremens 237 

Special  Symptomatology 237 

Etiologj' 238 

Results 240 

Pathological  Anatomy 240 

Diagnosis .' 240 

Alcoholic  Melancholia   241 

Alcoholic  Ilallucinatoiy  Paranoia 241 


Conlenis.  xiii 

PAGE 

3.  Chronic  Alcoholic  Psychoses 242 

Results 244 

Pathological  Anatomy 244 

Treatment   244 

( h )    Morphinism 245 

(c)    Cocainism    248 

Apj^endix  249 

Other   Intoxications,    as   Chloroforraism,    Ethero- 

mania 249 

4.  Psychoses  which  are  Erouglit  on  by  Inorganic  Poisons 249 

Carbonic  Oxide 249 

Poor  Gas 249 

Carbonic  Bisulphide 250 

Iodoform    250 

Lead   250 

Quicksilver    250 " 

v.  The  Organic  P.sychoses 251 

1.  Diffuse  Diseases  of  the  Brain  Cortex 251 

(a)    Progressive  Paralysis  of  the  Insane 251 

1.  The  Demented  Form 251 

2.  The  Classic  or  Typical  Form 254 

3.  Agitated  Form  .". , 254 

4.  Depressive  Form 254 

5.  Circular  Form 254 

6.  Ascending  Form 255 

Special  Symptomatology 255 

Etiology 261 

Outbreak    263 

Course 263 

Duration    263 

Results 264 

Pathological  Anatomy 264 

Diagnosis 265 

Prognosis  267 

Treatment   268 

( h )    Senile  Dementia 268 

(c)   Arteriosclerotic  Psychoses   272 

Paralysis  Agitans 273 

Encephalitis  Haemorrhagica 273 

Pachynneningitic  Psychoses    273 

((Z)    vSyphilitic  Psychoses 273 

Hereditary  Syphilis 274 

2.  Psychoses  which  are  Called  Forth  by  Focal  Disease  of  the 

Brain    275 

(a)    Psychoses  After  Apoplectic  Attacks 275 

(&)    Psychoses  from  Brain  Tumors 276 

Svipplement :    Psychoses  from  Traumata 277 


Instruction   for   the   Examination   of   a   Person   ]\lentally   Diseased, 

and  for  Rendering  an  Opinion  on  Such  a  Person 282 


Index  of  Subjects 303 


ILLUSTRATIONS. 


[Collins) 


Minor-writing 

Degrees  of  Craniofacial  Angle.     Prognathism 

Fig.    1.     Facial  angle-  of  man. 
"       2.     Type  of  prognathous  European. 
"       3      Facial  angle  of  the  ohimpansce. 
«       4.     Prognathous    skull    of   a   criminal    Italian   woman. 

(Lombroso.) 
«       5.     A  peasant  ^vith  sanguinary  instincts.      (Shack.) 


83 
S6 


Types  of  Cranial  Deformity. 
Microcephalus. 
^;ormal. 
Macrocephahis. 
Dolichocephalus. 
Brachycephalus. 
Leptocephalus. 


Trigonocephalus. 

Sphenocephalus. 

Oxyeephalus. 

Platycephalus. 

Trochocephalus. 

Piagiocephalus. 


(xiv) 


INTRODUCTION. 


Mental  diseases  are  diseases  of  the  brain.  Since  mental 
activity  has  its  seat  in  tlie  cortex  of  the  brain,  it  may  be  stated 
more  specifically  that  mental  diseases  are  diseases  of  the  brain 
cortex. 

Not  all  diseases  of  the  brain  cortex,  however,  engender 
mental  disease ;  many  of  the  focal  diseases  run  their  course  with- 
out mental  obliquity;  a  diffuse  disturbance  of  the  function  of 
the  cortex  of  the  brain  is  necessary  for  the  development  of  mental 
diseases;  these,  accordingly,  represent  diffuse  disturbances  of 
tlie  brain  cortex. 

It  is  not  known  at  present  what  pathological  processes  are 
present,  which  of  them  lead  to  a  mental  disturbance  or  to  a  de- 
lusion, or  the  nature  of  the  physiological  processes  which  lead  to 
normal  thought.  What  is  offered  as  an  explanation  is  in  reality 
only  an  interpretation  of  the  facts. 

Since  we  still  lack  a  physiology  of  the  mental  processes  we 
cannot  do  without  the  old  traditional  psychological  conceptions, 
if  we  wish  to  understand  certain  facts. 

Sense-impression  is  the  point  of  departure  for  each  mental 
activity.  It  is  subjective  in  so  far  as  it  is  conditioned  by  the 
state  of  its  own  body;  objective,  in  so  far  as  it  gives  us  a  report 
of  the  relations  of  the  outer  world. 

Sense-impressions  have  a  determined  localization  in  the 
brain  cortex;  the  sense  of  vision  has  its  center  in  the  cortex  of 
the  occipital  lobe  in  the  neighborhood  of  the  fissura  calcarina, 
the  sense  of  hearing  in  the  superior  gyrus  of  the  lobus  temporalis, 
the  sense  of  smell  and  taste  in  the  lobus  falciformis,  the  muscle- 
sense  probably  in  the  central  convolutions  and  in  the  lobus 
parietalis  superior.  We  assume  that  each  sense-impression,  if 
it  is  of  a  certain  degree  of  strength,  produces  a  molecular  change 
in  the  nerve  cells  affected,  which  gives  the  possibility  of  a  repro- 
duction, that  is,  a  reawakening,  by  an  internal  process. 

This  capability  of  reproduction  is  called  the  memory  of  the 
senses.     Corresponding  to  the  localization  Just  now  discussed, 

(1) 


Introduction. 


each  sense  has  its  own  memory.  The  sense-perception  is  devel- 
oped from  the  sense-impression,  which  already  represents  a  mo?t 
complicated  process  in  the  brain  cortex. 

I  am  sensible  of  the  light  which  jjroceeds  from  a  star.  In 
order  to  perceive  a  star,  that  is,  in  order  to  recognize  that  light 
as  proceeding  from  a  star,  the  fact  is  connected  with  that  per- 
ception of  light  that  I,  in  order  to  feel  the  light,  must  turn  my 
eye  upwards,  must  bend  my  head  backwards,  because  the  body 
from  whicli  the  light  proceeds  is  small,  because  it  is  at  an  endless 
distance. 

For  the  establishment  of  these  last  facts,  conclusions  serve 
which  were  drawn  from  the  muscular  feelings  which  come  from 
the  various  states  of  contraction  of  the  muscles  of  the  eye, 
of  the  neck,  of  the  pupils.  Each  component  which  leads  to  the 
percepiion  of  the  star  is,  according  to  this,  a  complicated  percep- 
tion which  has  its  point  of  departure  in  other  regions  of  the 
brain  cortex  than  that  in  which  the  sensil^ility  to  light  has  its 
seat. 

The  anatomical  possibility  of  the  connection  of  these  dif- 
ferent regions  rests  in  the  great  development  of  the  system  of 
association  fibers.  Finally,  for  the  perception  of  the  star  as  a 
star,  the  comparison  and  identification  of  this  latter  with  a  pre- 
ceding circumstance  is  necessary,  whose  result  is  designated  as 
the  perception  of  a  star. 

We  designate  as  an  idea  the  reproduction  of  previous 
sense-perceptions.  I  picture  to  myself  a  landscape  which  I 
liave  seen.  Tlie  mental  process  which  brings  about  the  connec- 
tion of  the  ideas  is  called  thinhing. 

The  association  of  the  ideas  follows  determined  laws,  of 
which  Aristotle  distinguished  four:  that  of  similarity,  that  of 
contrast,  that  of  co-existence,  and  that  of  succession,  by  which 
not  only  the  nearness  of  space,  but  also  of  time,  comes  into  con- 
sideration. 

Of  the  numerous  laws  of  association  brought  forward  later, 
only  Hume's  law  of  cause  and  effect  (better,  motive  and  conse- 
quence) appears  to  be  of  any  practical  importance.^ 

The  greatest  role  is  undoubtedly  played  by  the  connection  of 

^  Although  these  laws  of  association  are  very  imperfect,  hitherto  we 
have  not  been  able  to  replace  them  by  anything  better. 


Introduction. 


synchronous,  or  better,  since  there  must  always  be  a  certain  inter- 
val of  time  between  two  sense-perceptions,  by  the  connection  of 
ideas  immediately  following  one  another  (succession). 

If  the  same  paths  are  often  used  in  the  same  way,  they  be- 
come "worn,"  "familiar;"  a  "chain  of  associations,"  or  a  "series 
of  associations,"  is  formed  as  soon  as  the  first  point  of  departure 
is  fixed,  and  from  this  results  the  ease  and  apparent  immediate- 
ness  of  the  perception  and  the  idea.  By  the  separation  of  the 
important  from  the  regularly  appearing  content  of  a  deter- 
mined series  of  connected  ideas  from  the  unimportant,  the  ac- 
cidental and  the  intermittent,  arises  conception j  from  the  syn- 
thesis of  the  conceptions  comes  the  judgment;  and,  finally,  from 
the  judgments,  the  conclusion,  which  is  the  final  result  of  the 
different  ideas  which  have  met  and  struggled  for  supremacy  in 
the  path  of  the  associations. 

Even  the  products  of  thought  which  are  gained  in  this  man 
ner  have  the  power  of  reproduction,  so  that  it  is  not  necessary 
for  us  in  each  single  instance  to  wander  anew  through  all  the 
paths.  The  word  by  which  we  designate  the  determined  concep- 
tion, judgment,  or  conclusion,  makes  such  a  reproduction  essen- 
tially easier. 

There  is  a  second  peculiarity,  besides  the  capability  of  re- 
production, which  resides  in  the  sense-impressions,  sense-per- 
ceptions, and  thoughts  accompanied  by  inward  feelings.  They 
may  be  in  reference  to  their  quality,  feelings  of  pleasure,  or 
feelings  of  displeasure.  There  is  often  an  interference  or  zero 
point,  at  which  neither  the  one  nor  the  other  feeling  clearly 
appears. 

Sense-feelings  are  those  connected  with  sense-impressions 
or  sense-perceptions,  subjective  or  objective,  and  their  reproduc- 
tions; feelings  of  the  judgment  are  those  which  accompany  the 
activity  of  thinking  and  the  judgments  arising  therefrom. 

To  the  last  belong: 

1.  The  ethical  feelings  (good  and  bad).  We  distinguish 
egoistic  and  altruistic  feelings:  AVhile  the  former  are  con- 
genital and  show  the  feeling  of  pleasure  in  furthering  one's  own 
interests,  and  the  feeling  of  displeasure  when  obstacles  arise,  the 
latter  are  the  product  of  education  and  reach  their  highest  point 


Introduction. 


in  interosl  ior  fellow-man,  which  is  placed  equal  to  one's  own, 
and  in  some  circumstances  even  higher.  To  these  altruistic 
feelings  belong  the  sentiments  of  friendship,  of  sympathy,  of  pity 
(social  feelings). 

2.  The  religious  feelings:     Piety  and  impiety  as  a  contrast. 

3.  The  esthetic  feelings:  "Beautiful"  and  ''ugly,"  "sub- 
lime" and  "depraved." 

4.  The  logical  or  intellectual  feelings :  Feelings  of  pleasure 
if  the  mental  labor  is  perfected  quickly  and  without  hindrance; 
feeling  of  displeasure  on  opposition,  doubt,  or  delay. 

Sense-perception,  thought,  memory,  and  feelings  are  the 
foundations  of  intellectual  activity,  the  primary  functions  of  the 
organ  of  the  psyche. 

The  sum  of  all  the  sense-perceptions  momentarily  present, 
of  ideas  and  their  products,  as  well  as  of  what  has  been  pre- 
viously present  and  is  reproducible,  is  the  consciousness;  the  sum 
of  the  feelings,  connected  with  the  content  of  the  consciousness, 
we  designate  as  mind. 

If  a  determined  perception  or  a  determined  idea  of  special 
power  is  dominant  in  the  consciousness  momentarily,  it  arouses 
those  associated  with  itself  and  presses  back  those  foreign  to  it; 
thus,  we  speak  of  attention  in  a  certain  direction;  in  a  similar 
manner  the  frame  of  the  mind  shows  a  inomentary  situation  of 
the  mind. 

By  emotion  we  understand  the  sudden  change  of  the  frame 
of  the  mind  induced  by  inner  or  outer  influences  connected  with 
violent  shock  to  the  consciousness,  so  that  there  results  a  distur- 
bance in  the  efflux  of  the  ideas,  a  temporary  disturbance  of  the 
inner  equilibriuni,  and  of  circumspection,  and  which  is  often 
followed  by  abnormal  actions. 

The  keystone  of  the  arch  of  our  psychic  activity  is  the  devel- 
opment of  self-consciousness.  The  consciousness  of  one's  own 
personality,  in  association  with  and  in  contrast  to  the  outer 
world  and  the  perception  of  the  continuity  of  this  relation,  con- 
stitutes the  Ego. 

As  the  conception  is  developed  from  the  ideas,  so  the  concep- 
tion of  the  Ego  is  developed  from  the  reproduced  contents  of  the 
consciousness,  which  are  always  arranging  themselves  in  new 


Introduction. 


forms  while  tlic   important,  regularly  appearing,  presses  back 
the  unimportant,  accidental,  and  changeable. 

Besides  sense-perceptions,  ideas,  and  feelings,  and  the 
capability  of  reproduction  of  these  phenomena,  there  is  no  such 
primary  function  of  the  psyche  which  one  might  designate  as 
will  The  so-called  arbitrary  actions,  which  have  been  l:)rought 
forth  from  the  will,  proceed  from  the  end  of  a  series  of  ideas 
which  are  partially  directed  to  the  completion  of  an  action  (as- 
sociating), partly  to  its  omission  (contrasting). 

The  developing  process  of  association  l^etween  the  inner  or 
the  outer  excitation  which  gives  the  motive  to  the  completion  of 
an  action  and  the  movement  which  unfolds  it,  is  called  reflection. 
In  the  struggle  of  ideas,  the  greater  or  less  power  of  the  motives 
pressing  for  the  action,  or  demanding  its  omission,  finally  de- 
cides in  which  are  present,  on  one  side,  habits,  well-worn  paths 
the  conceptions  of  the  Ego,  and,  on  the  other,  are  suddenly  press- 
ing sense-perceptions  and  thought-ideas,  with  which  the  accom- 
panying feelings  are  of  peculiar  significance. 

The  will  is  ''an  idea  horn  from  an  idea,  and  generating  ideas  . 
of  special  accentuation." 

A  part  of  the  apparently  arbitrary  actions  appear,  on  more 
exact  analysis,  to  be  refl.ex,  called  forth  by  sense-perceptions, 
passing  over  upon  the  motor  apparatus  by  well-worn  ways. 

A  series  of  other  actions  are  brought  about  by  instincts. 
These  are  strong  sense-feelings  pressing  for  satisfaction ;  they 
reach  the  re-establishment  of  an  inner  equilibrium  by  their 
satisfaction. 

Finally,  the  actions  in  the  emotions  are  reflex,  that  is,  re- 
leased by  the  shattering  of  the  content  of  consciousness  without 
the  intervention  of  thought-ideas.  The  reflex  action  of  the  emo- 
tions on  the  motor  paths  is  shown  in  the  course  of  the  same. 
One  after  another,  the  paths  of  the  oculomotor  (starting  eyes, 
change  of  the  position  of  the  eyes),  of  the  trigeminus  (gnashing 
of  the  teeth),  of  the  facialis  (spasmodic  expression  of  the  face), 
of  the  vagus  (palpitation  of  the  heart),  etc.,  are  attacked. 

According  to  this,  the  discussion  of  the  pathological  dis- 
turbances of  mental  activity  would  have  to  treat  of : — 

I.  Disturbances  of  the  sensation  and  the  sense-perception, 

II.  Disturbances  of  thought, 


6  Introduction. 


III.  Disturbances  of  the  power  of  reioroduction, 

IV.  Disturbances  of  the  feelings  accompanying  these 
psychic  phenomena. 

From  these  disturbances  must  result  spontaneously  the  dis- 
turbances of  the  consciousness,  of  the  self-consciousness,  and  of 
action. 


PART  I. 

General  Psychiatry. 


A.    General  Symptomatology. 

I.  THE  DISTURBANCES  OF  SENSATION  AND 
SENSE  PERCEPTION. 

These  may  take  their  point  of  departure  in  diseases  of  the 
superficial  terminal  apparatus,  of  the  sensory  conductors,  or  of 
the  cortical  centers.  The  disturbance  of  these  functions  may 
consist  of  hyperesthesia,  paresthesia,  or  anesthesia  (hypesthesia). 

1.  Hyperesthesias  and  Paresthesias  Originating  in  Disease 
of  the  Superficial  Terminal  Apparatus  and  of  the 
Sensory  Conductors. 

The  elaborate  discussion  of  these  phenomena  is  the  task  of 
the  special  pathology  of  the  nervous  sj^stem.  In  this  place  only 
those  facts  will  be  made  prominent  which  may  be  of  clinical  and 
sometimes  of  therapeutical  significance  in  mental  diseases.  Here 
belong  the  hyperesthetic  condition  of  the  optic  nerve  which  is 
called  forth  by  opacities  of  the  vitreous  body,  choroiditis,  neuritis 
oj)tica,  and  which  show  themselves  {entoptic  phenomena)  as  light 
phenomena  (stars,  flashes,  photopsias),  and  as  the  seeing  of 
fiery  and  colored  mists. 

In  the  sense  of  hearing  entotic  phenomena  appear  as  roar- 
ing, hissing,  whistling,  and  noises  which  may  arise  from  furuncu- 
losis,  or  the  accumulation  of  cerumen  in  the  external  auditory 
canal,  by  auto-perception  of  the  venous  murmur  in  the  chlorotic, 
by  the  dilatation  of  the  bulbus  vcnaa  jugularis,  by  atheroma  of  the 
arterial  walls  (especially  frequent  in  the  beginning  of  dementia 
senilis) . 

(7) 


8  General  Symptomatology. 

Putrid  and  offensive  sensations  of  taste  (psychoses  with  re- 
fusal to  take  food)  may  be  called  forth  by  fur  on  the  tongue  and 
its  decomposition,  especially  with  faulty  reception  of  nourish- 
ment. Finally,  neuritis  engenders  paresthetic  sensations  of  the 
skin,  tingling,  formication  (tabes,  alcoholism,  diabetes). 

All  these  disturbances  may  be  the  point  of  departure,  in  the 
menttilly  diseased,  for  the  development  of  hallucinations.  They 
often  give,  according  to  their  localization  and  nature,  a  special 
significance  to  the  false  ideas. 


2.  Hyperesthesias  of  the  Sensory  Centers  of  the  Cortex 
and  Their  Paths  of  Association. 

AVe  know  from  neuropathology  the  increased  irritability  of 
the  cortical  sense  centers  in  hysteria.  This  increased  irrita- 
bility affects  sight,  hearing,  smelling,  taste,  and  the  senses  of 
touch  and  of  motion  are  equally  affected.  Increased  irritability, 
especially  of  sight  and  hearing,  is  often  found  in  the  melan- 
choliac;  every  impression  of  light,  every  noise  gives  him  pain. 
The  heightened  irritability  of  the  emotions  distinguishes  the  con- 
ditions of  mania. 

The  so-called  after-sensations  are  to  be  designated  as  a  con- 
sequence of  heightened  irritability :  an  irritation,  which  was  once 
formed  from  an  external  impression,  remains  for  hours  (Xewton 
saw  the  sun,  which  he  had  fixed  his  eyes  upon  before,  in  full  splen- 
dor in  a  dark  chamber  for  a  long  time  afterwards;  one  of  my 
patients  heard  for  hours  the  sound  of  bells  before  which  he  had 
fled  and  which  for  a  long  time  had  ceased  to  be  audible) .  Such 
after-sensations  are  observed  in  certain  intoxication  psychoses 
(hashish),  in  hysteric  psychoses,  and  in  melancholia,  in  which 
latter  they  may  especially  increase  the  anxiety. 

In  the  series  of  hyperesthetic  conditions  belongs,  also,  the 
facile  impressibility  of  the  association  fibers  connecting  the  sen- 
sory centers  which  condition  the  so-called  secondary  sense-im- 
pressions^ (co-sensibility,  double  sensibility).  "With  an  auditory 
deception  appears  contemporaneously  a  color  sensibility  (audition 
colorce,  Schallphotismen,  or  sound  photism),  in  which,  generally, 


•  Koppe,  Deutsche  Medicinische  Wocheusehrift,  1S99,  No.  35. 


IfijpcreHUiesia  of  Sensorij  Centers  9 


clear,  deep  tones  call  forth  dark  colors.  The  perceptions  of 
color  are  often  connected  with  the  sight  of  certain  numbers  and 
letters  (pseudochromesthesia). 

Impressions  of  smell  and  taste  may  likewise  call  forth  cer- 
tain colors  (in  drinking  acid-liqnids,  a  blue  color,  or  in  drinking 
vinegar,  a  red  color)  (pliotism  of  smell  and  taste,  olfaction  and 
gustation  coloree). 

Noises  are  not  often  perceived  with  sensations  of  light 
(light-phonism).  Contrariwise,  Koppe  observed  smell-phonism 
(the  smell  of  resin  on  the  whistling  of  a  tune) . 

More  often  sight-perceptions  are  connected  with  obscure 
feelings  of  movement,  as,  for  example,  on  looking  down  from 
a  great  height  paresthesias  appear  in  the  legs. 

Such  secondary  sense-impressions  are  observed  in  the 
healthy  as  well  as  in  neurasthenics,  in  hysteric  psychoses,  in  mel- 
ancholiacs,  and  also  in  paranoic  conditions.  In  the  framing  of 
these  secondary  sensations  also  belong  those  observations  in  which 
the  patient,  on  seeing  certain  persons,  has  marked  sensations  at 
some  point  of  the  body,  for  example,  in  the  gastric  region  or  on 
the  tongue. 

Finally,  the  hyperesthesia  of  the  sensory  centers  essentially 
calls  forth  the  so-called  hypochondric  sensations. 

It  cannot  be  doubted  that  the  internal  organs,  as  well  as  the 
sensory  apparatus  and  the  extremities,  have  their  central  pro- 
jection, that  is,  that  each  organ  has  its  reflection  in  the  brain. 
At  the  present  time  we  do  not  know  the  localization  of  these 
centers.  It  is  possible  that  they  have  a  sub-cortical  center,  per- 
haps in  one  of  the  large  ganglia.  As  long  as  the  bodily  organs 
are  in  their  normal  condition,  we  are  not  cognizant  of  them,  we 
feel  neither  our  heart  nor  our  liver.  A  special  irritation,  a 
pathological  condition  of  a  certain  organ,  brings  us,  by  the  irri- 
tation which  is  conveyed  centripetally  to  the  center,  to  a  con- 
sciousness of  the  trouble ;  we  feel  the  diseased  organ. 

A  hyperesthesia  of  the  diseased  center  may  awaken  in  it  the 
most  varied  sensations  by  the  law  of  eccentric  sensibility,  as  com- 
pared with  the  normal  nature  of  the  diseased  organ:  Anomaly 
of  the  subjective  sense-impression,  lujpocli  oneiric  sensations. 

In  this  description  of  the  hyperesthesia  of  the  sensory  cen- 
ters we  treat  only  of  the  simple  phenomena,  adequate  to  the 


10  General  Symptomatology. 


specific  physiological  function  of  the  nerve.  But  in  h3i3eresthe- 
sias  of  the  sensory  centers,  further  central  phenomena  may  be 
developed  in  the  life  of  ideas,  \vhich  lead  to  complicated  sensory 
pictures.     We  designate  these  by  the  name  of : 

3.  Hallucinations^  or  Sensory  Deceptions. 

In  this  is  included  in  the  pathological  process  not  only  the 
sensory  impression,  but  also  the  complicated  association  process 
which  we  call  sense-i^erception. 

Hallucinations  are  sense-perceptions  without  an  exterior 
object  present.- 

They  ajjpear  in  all  the  senses. 

The  hallucinations  of  sight  may  be  of  a  simple  elementary 
nature  and  form,  as  such,  transitions  from  the  irritation  phe- 
nomena of  optics  to  hallucinations:  Seeing  lightning,  rainbow 
colors,  pillars  of  fire,  fiery  wheels,  and  other  such,  things.  Or 
they  are  of  a  composite  nature :  Animal  forms,  rats,  mice 
(zoopsy),  human  shapes,  the  dead,  angels,  God,  whole  proces- 
sions, masquerades,  "phantasmagorias.'^ 

Sometimes  the  picture  of  hallucination  sliows  the  person 
himself  (second  sight),  also  as  a  ""corpse"  or  "flying  througli  the 
space  of  the  universe"  (oftener  observed  by  epileptics,  Goethe 
on  his  return  from  Sesenlieim) . 

Generally  the  pictures  have  something  shadowy,  oftener 
they  appear  as  "mirrorings"  like  the  pictures  of  a  magic  lantern, 
consequently  without  depth ;  but  are  sometimes  clear  and  shining. 

Many  pictures  appear  without  motion,  always  in  the  same 
place  and  in  the  same  manner  (stable  hallucinations)  ;  others 
pass  by  the  observer,  come  up  to  him  or  move  away  from  him, 
become  larger  or  smaller  (agitated  hallucinations  in  maniacal 
states,  in  delirium  tremens). 

Many  patients  see  even-thing  of  unusually  large  size  (ma- 
cropsia)  ;  others,  ever}"thing  ver}-  small  (micropsia). 

The  movement  of  the  images  of  hallucination  and  their 
changing  magnitude  are  generally  coimected  ^vith  hallucinations 

^  Hallucinari  comes  from  alucus,  a\o\v^eiv,  ululari.  which  is  formed 
onomatopcetically  from  the  hooting  of  owls.  It  is  probable  that  this  word 
was  at  first  ahicinari:     fo  behave  like  night  birds,  to  shriek  and  hoot. 

*  Mendel,  Klinische  Wochenschrift,  1S90,  page  578. 


Ilallucinations.  11 


of  the  muscular  feeling  in  the  region  of  the  interior  and  exterior 
muscles  of  the  eye. 

Quite  often  a  dilated  joupil  in  the  patient  corresponds  with 
the  perception  of  a  hallucination  at  a  distance,  while  a  contracted 
])upil  corresponds  with  such  a  one  close  by.  Another  connection 
of  sight  hallucinations  with  hallucinations  in  the  feelings  of  i\Mi 
muscles  (writing  center)  is  that  the  patient  writes  (or  sees  writ- 
ten) his  thoughts  on  the  wall,  "in  the  air"  (photography  of 
thought). 

The  hallucinations  of  audition  are  either  of  an  elementary 
nature  (tone  a  by  the  composer  Schumann,  cracking,  shooting, 
rushing  of  water)  or  of  a  complicated  nature:  Hearing  single 
words  or  sentences  ("rascal,"  "Don  Juan  of  the  water-works," 
"you  must  marry"),  speeches  of  one  or  more  persons,  men, 
Avomen,  children,  "a  whole  mob";  sometimes  different  languages 
are  heard,  quite  often  rhymes  or  whole  verses.  The  voices  are 
olten  low  at  first,  then  plainly  heard  as  if  coming  nearer.  Gen- 
erally the  voice  is  in  a  whisper,  but  sometimes  loud:  "Trumpet 
tones,"  "they  yell  in  my  ear." 

In  many  cases  the  patient  answers  the  voice  which  he 
hears,  carries  on  a  conversation  with  it. 

Sometimes  the  hallucinations  of  audition  are  first  called 
forth  by  hallucinations  of  sight :  The  patient  sees  a  shadow,  this 
begins  to  speak. 

With  the  hallucinations  of  audition  belongs  also  the  audibil- 
ity of  one's  own  thoughts.^ 

At  first  it  is  only  a  "catch-word"  spoken  to  the  patient, 
arising  from  the  momentary  idea,  for  example,  with  the  thought 
of  father,  "father,"  or,  with  the  thought  of  death,  "death."  The 
hearing  of  such  words,  generally  softly  spoken  at  first,  causes 
great  disquiet  and  unrest  to  the  patient  in  regard  to  the  unheard- 
of  and  horrible  thing  which  happens  him ;  gradually  he  elaborates 
the  occurrence  into  his  system  of  delusions,  and  then  a  condition 
is  developed  in  which  these  catch-words  are  clothed  in  an  allocu- 
tion, as :  "Now  he  thinks  of  his  father,"  "Kow  he  thinks  of  his 
death."    This  is  an  "echo  of  the  thought;"  they  "take  away  his 


'  Cramer,  Die  Hallucinationen  im  Muskelsinn  bei  Geisteskranl^cn. 
Freiburg,  1889. 


12  General  Symptomatology. 


thoughts."'     Contemporaneously  movements  of  tlie  lips  and  of 
the  tongue  are  sometimes  perceived. 

The  phenomena  in  which  the  patient  believes  from  the 
mien,  the  expressions,  actions  of  his  environment,  from  the  re- 
ports of  newspapers,  that  his  innermost  thoughts  have  become 
known  ("truly  vou  know  it"),  must  be  distinguished  from  this 
audibility  of  thought  Here  it  concerns  an  elaboration  of  per- 
c-eptions  in  the  sense  of  a  system  of  delusion.  Hallucinations 
of  sense  of  touch  or  of  the  ccenesthetic  sense  about  the  head  (sen- 
sation of  becoming  "electrified"  or  "magnetized")  may  support 
the  patient  in  the  conviction  that  people  "strip  him  of  his 
thoughts,"  "that  his  ideas  are  being  taken  from  him." 

In  thoughts  becoming  audible  one  may  imagine  that  ret- 
rograde agitation  from  the  conception  incites  the  hyperesthetic 
acoustic  picture  belonging  to  it,  and  this  appears  as  hallucination. 
This  would  be  essentially  the  same  process  in  the  sense  of  hearing 
as  that  designated  as  vision  in  the  visual  sense :  Sight  hallucina- 
tions which  are  called  forth  by  conceptions. 

This  audibility  of  thought  often  remains  clear  for  some 
time  in  reading  and  writing.  The  spoken  or  writteti  word,  that 
is,  the  conc-eption  taken  up  with  it  or  which  is  to  be  expressed, 
is  called  out.  "I  can  write  no  more,  since  each  word  which  is 
written,  even  before  it  is  written,  is  called  aloud  by  a  man  in  the 
garden  and  c-ommunicated  to  all." 

The  hallucinations  of  taste  and  smell,  which  generally  can- 
not be  separated,  or  only  with  difficulty,  from  the  illusions  of 
these  senses,  have  mostly  a  disagreeable  content:  The  patient 
tastes  "asafetida,"  '%ruie  and  excrement,"  "laimian  flesh.''  He 
smells  "corpses,"  "sulphur  vapor,"  "carrion,"  "perspiration." 
Agreeable  hallucinations  seldom  appear  in  these  senses,  but  may 
appear  especially  in  hysteric  psychoses:  'TIeavenly  sweetness," 
"attar  of  roses,"  "patchouli." 

The  h}-pochondric  delusions  are  to  be  distinguished  from 
these  hallucinations;  in  those  cases  where  the  patient  says  that 
he  feels  badly  after  eating,  that  he  has  diarrhea,  dizziness,  result- 
ing from  it,  and  now  concludes  that  poison  must  have  been  in 
the  food ;  but  he  explains,  on  being  asked,  that  he  has  not  smelt 
or  tasted  it.  Many  of  the  apparent  hallucinations  of  taste  are 
hallucinations  of  the  sense  of  touch  of  the  tongue  (feeling  of 


B  allucinations.  13 


"pricking,"  "roughness/"'  "needles,"  "glass-splinters,"  "hair"  in 
the  food). 

The  hallucinations  of  touch  (cutaneous  hallucinations) 
manifest  themselves  as  having  fur,  formication,  pricking,  tick- 
ling, being  sprinkled,  the  running  around  of  rats,  snakes  on  the 
body,  electrifying,  magnetizing,  as  pushing,  striking,  fettering, 
as  the  feeling  of  small  bodies  under  the  skin  (see  cocaine 
psychoses). 

In  the  domain  of  the  temperature  sense  hallucinations  ap- 
pear as  perception  of  "passing  a  cold  sponge  over  the  body,"  "lay- 
ing a  cold  hand  on  the  forehead,""  "a  branding-iron  on  the  body," 
"pouring  on  boiling  water,"  and  the  like. 

The  hallucinations  in  the  muscle  sense,  so  far  as  they  affect 
the  muscles  of  the  eye,  have  already  been  spoken  of  under  the  hal- 
lucinations of  vision.  Hallucinations  of  the  muscle  sense  of  the 
organs  of  speech  (motor  speech  center)  may  call  forth  an  internal 
speech. 

The  patient  hears  some  one  speak  within  himself.  "There 
is  a  thought  speech,"  "there  is  a  sixth  sense,"  "a  speech  is 
brought  to  me."  Corresponding  to  the  system  of  hallucination, 
the  internal  speech  is  attributed,  to  certain  persons :  "Meyer 
speaks  in  me,"  "the  evil  one  sjjeaks  in  me." 

With  the  further  development  of  such  a  pathological  condi- 
tion it  may  reach  the  doubling  or  even  the  tripling  of  the  per- 
sonality :  Two  inimical  jDowers  speak  in  the  head,  the  third,  who 
must  suffer  during  the  strife,  is  then  the  diseased  person. 

The  occurrence  of  internal  speech  TUdij  be  explained  in  the 
following  manner:  Even  in  normal  conditions  an  agitation  of 
the  motor  speech-images  generally  takes  place  during  thinking, 
which  often  enough,  especially  when  a  lively  conception  occupies 
us,  causes  a  slight  movement  of  the  lips  and  tongue. 

In  pathological  conditions  the  phenomenon  of  agitation, 
which  goes  from  the  conception  through  the  sound  center  to  the 
motor  center,  may  become  retrograde.  The  motor  word-images, 
when  first  aroused  and  led  through  the  sound  center,  are  heard 
by  the  Ego  as  words  spoken  within  itself :  it  hears  the  speaking 
within  itself. 

Peculiar  states  of  agitation  are  connected  with  these  hallu- 
cinations in  the  centers  of  the  sensations  of  the  different  organs; 


14  General  Symptomatology. 

thus  the  patient  may  get  the  impression  that  the  speech  came 
from  the  stomach,  the  abdomen,  or  the  breast. 

Kinesthetic  Hallucinations. 

The  tactile  feelings  of  the  skin,  the  centripetal  agitation  of 
the  superficies  of  the  joints,  of  the  tendons  and  muscles,  bring  us 
tidings  of  the  conditions  of  our  limbs  and  their  motion  (kines- 
thetic feelings). 

The  pathological  central  stimulus  of  these  impressions  may 
call  forth  hallucinations.  Patients  feel  wavering,  floating  in 
the  air,  believe  themselves  drawn  on  high  or  sunk  in  the  depths. 

From  this  the  delusions  receive  their  content,  that  the  pa- 
tients think  that  they  are  over  the  sea,  are  able  to  fly,  are  raised 
to  heaven  or  sunken  under  the  earth. 

The  degree  of  muscular  tension  is,  as  a  rule,  dependent  upon 
the  nature  and  intensity  of  the  centripetal  stimuli.  But  the  last 
may  be  supplied  by  hallucinations  in  the  kinesthetic  feelings,  and 
these  hallucinations  then  determine  the  muscular  tension.  The 
katatonic  tensions  may  generally  be  referred  back  to  such  hallu- 
cinations as  may  enter  with  or  without  delusions. 

Hallucinations  of  the  Cwnesthetic  Sense. 

If  the  h}T)ochondric  impressions  have  their  origin  in  a 
hj^peresthesia  of  the  cortical  or  subcortical  centers,  the  hallu- 
cinations of  the  coenesthetic  sense  carry  out  those  impressions  still 
further,  in  conformity  with  the  dominant  delusion;  and  the 
patient  asserts :  "My  head  is  of  glass,"  "my  stomach  has  simk 
down,"  "my  heart  has  twisted  from  its  place,"  "something  has 
come  out  of  my  back,"  "there  is  stone  before  my  anus."  In  severe 
cases,  and  generally  in  connection  with  other  hallucinations,  the 
delusion  arises  in  the  patient  that  his  entire  body  is  transformed, 
that  he  is  metamorphosed  into  an  animal,  a  wolf  (lycanthropia), 
a  dog  (cynanthropia). 

The  hallucinations  of  the  sexual  organs,  which  may  exist 
with  or  without  the  feeling  of  lust,  call  forth  the  statement  in 
men  that  they  have  had  erections,  have  emitted  semen ;  in  women, 
that  unseen  persons  have  had  connection  with  them,  that  they 
have  torn  out  the  vagina  and  uterus,  that  their  abdomen  swells, 
that  thev  feel  life. 


Hallucinations.  15 


The  elaboration  of  sexual  hallucinations  with  the  dominant 
system  of  mania  brings  fortli  the  succubi  and  incubi  (men  or 
women  who  believe  that  they  have  sexual  intercourse  with  the 
devil). 

When  a  hallacination  is  called  forth  by  an  external  object 
and  is  embodied  in  it,  we  designate  it  as  an  illiisioii.  Therefore, 
an  illusion  is  the  sensory  perception  of  an  external  object  changed 
hy  a  hallucination. 

Illusions  appear  in  all  the  senses;  in  the  sense  of  sight, 
clouds,  trees,  carpets  are  transformed  by  hallucinations ;  they  lead 
sometimes  to  the  symptom  of  non-recognition  of  persons.  The 
patient  believes  that  he  sees  an  acquaintance,  or  he  sees  acquaint- 
ances in  a  form  changed  by  his  hallucination.  He  sees  in  the  ex- 
pression of  the  faces  of  his  acquaintances  or  strangers  anxiety  or 
repulsion  (melancholia,  paranoia)  :  "Everything  is  so  strange 
to  me." 

Even  the  contours  of  his  own  body  sometimes  take  on 
another  shape,  e.g.,  on  looking  into  a  mirror  (hypochondric 
psychoses). 

The  external  stimulus  to  the  development  of  illusions  in  the 
sense  of  sight  often  lies  in  the  eyes:  The  shadows  which  the 
blood-vessels  of  the  internal  eye  cast  upon  the  retina,  and  after- 
images found  on  the  retina,  scotomas  (alcoholists),  a  broken 
crystalline  lens  may  give  the  stimulus  for  arousing  illusions, 
seeing  flies,  caterpillars. 

Many  patients  have  illusions  of  vision  only  with  open  eyes, 
others  only  when  they  are  closed. 

Illusions  in  the  sense  of  hearing  manifest  themselves  as 
words  of  abuse  in  the  rustling  of  leaves,  as  caresses  in  the  songs 
of  birds,  as  hearing  defamatory  and  injurious  words  in  the  inno- 
cent speeches  of  those  around  them,  in  the  utterances  of  passing 
strangers. 

Oftener  the  auditory  illusions  are  excited  by  disease  of  the 
peripheral  terminal  organs  (cerumen,  otitis  externa  and  interna). 
At  first  there  arise  only  noises,  ringing,  buzzing,  which  may  be 
perceived  in  the  ear  or  head ;  then  these  are  designated  as  coming 
from  the  outside,  and  finally  voices  are  added  to  them. 

Jolly  was  able  to  call  forth  artificially  such  illusions  by 
electric  excitation  of  the  acoustic  nerve.     It  has  already  been 


16  General  Symptomatology. 


stated  that  it  is  difficult  to  differentiate  hallucinations  and  illu- 
sions of  the  gustatory  and  olfactory  senses  with  certainty.  It 
should  only  be  mentioned  here  that  single  medicaments,  like  san- 
tonin, morphine,  even  in  the  form  of  subciitaneous  injections, 
may  call  forth  illusions. 

In  the  sense  of  touch,  neuritis,  touching  of  the  skin  through 
the  bed  covers,  folds  in  the  covering  or  the  shirt  may  call  forth 
illusions  which  have  the  character  of  the  above-mentioned  hallu- 
cinations, may  also  show  themselves  as  sensations  as  if  animals, 
fleas,  snakes,  were  moving  over  the  skin. 

In  the  same  manner  external  injuries  of  the  muscles  or  the 
kinesthetic  apparatus  may  furnish  the  incitation  for  the  illusions. 

The  illusions  in  the  coenesthetic  sense  are  very  frequent. 
The  pathological  change  of  an  organ  furnishes  the  point  of  de- 
parture for  the  deception.  Sometimes  the  most  careful  examina- 
tion will  not  disclose  such  a  disease,  and  the  autopsy  first  con- 
firms the  illusion.  A  patient  asserted  that  at  a  certain  point  of 
the  back  something  had  been  cut  out  of  his  body.  At  the  autopsy 
the  hallucination  was  shown  to  be  an  illusion:  near  this  place 
there  was  a  carcinoma  of  the  pancreas. 

As  at  the  periphery,  the  incitation  and  point  of  departure 
for  a  hallucination  may  lie  in  the  imaginative  life. 

The  apparitions  of  vision  are  well  recognized:  An  intense 
dominant  conception  calls  forth  a  sensory  image  corresponding 
to  itself  (intense  occupation  with  di^^ne  things :  an  angel  ap- 
pears, Luther's  hallucination  on  the  Wartburg). 

There  are  healthy  men  who  are  able  to  call  forth  such  sen- 
sory images  (hallucinationes  voluntarite)  ;  they  are  observed 
oftener  in  psychoses,  especially  hysteric  psychoses,  in  alcoholists, 
also  in  maniacal  states.     "I  see  what  I  wish." 

Hallucinations  and  illusions  may  appear  on  one  side.^  This 
is  especially  observed  in  the  senses  of  sight  and  hearing.  Hallu- 
cinations, like  illusions,  may  be  imilateral  and  especially  observed 
in  the  auditor}^  and  visual  senses,  almost  always  on  the  left  side. 
Such  unilateral  hallucinations  are  observed  in  hysteric  and  epi- 
leptic psychoses  ("red  cog-wheel  on  the  left  eye"  as  aura  of  an 
epileptic  attack,  "the  crow  of  a  cock,"  "howling  of  beasts"  on  one 


"■Higier,  Ueber  iinilaterale  Halhicinationen.     Wiener  Klmik,  1894. 
Robertson,  Journal  of  Mental  Sciencej  1901,  April. 


Hallucinations.  17 


side  by  epileptics,  "W'aelit  am  Ehein"  on  tlie  left  side  in  a  hys- 
teric psychosis)  ;   very  often,  also,  in  alcoholism. 

In  the  sense  of  vision  the  unilateral  hallucinations  often 
combine  with  hemianopsia. 

In  all  these  cases,  in  which  the  normal  sense-perception  ex- 
ists on  the  side  not  attacked,  the  most  careful  examination  of  the 
peripheral  organs  is  necessary,  since  there  are  often  illusions 
A\-hich  take  their  point  of  departure  from  some  pathological 
change  in  those  organs. 

In  the  sense  of  touch,  unilateral  hallucinations  manifest 
themselves  as  a  feeling  of  pulling  on  one  ear,  as  the  presence  of  a 
second  person  at  the  hallucinated  side. 

Bilateral  hallucinations  may  have  a  different  content  on  the 
two  sides  (hallucinations  dedoublees). 

The  patient  imagines  a  man  before  one  eye,  a  woman  before 
the  other,  hears  with  one  ear  "rascal,"  with  the  other  "darling." 

A  voice  on  one  side  advises  the  patient  to  do  a  certain  thing, 
a  second  on  the  other  side  warns  him  against  it. 

A  "spirit,"  accompanying  the  patient,  takes  him  by  the  right 
ear  if  he  does  anything  bad,  by  the  left  if  something  good. 

Often  common  duplex  hallucinations  are  associated  with 
these  unilateral  and  bilateral  ones;  the  first  appear  only  inter- 
mittently, and  sometimes  they  replace  the  duplex  ones  and  later 
on  are  merged  into  the  bilateral  hallucinations. 

Bilateral  hallucinations  which  are  designated  as  antagonis- 
tic or  contrasting  hallucinations  are  those  which,  while  appearing 
in  one  or  more  senses,  contradict  each  other  by  their  content,  as 
we  have  seen  with  the  bilateral  hallucinations  with  different  con- 
tent.    They  appear  to  the  patient  as  a  mutual  negation. 

Secondary  hallucinations  (reflex  hallucinations)  appear 
similar  to  the  secondary  sensations.  With  these  the  primary 
sense  impression  may  be  a  real  sense  perception  or  a  hallucina- 
tion. 

The  patient  hears  his  name  called  and  feels  a  push  in  his 
stomach ;  after  a  certain  olfactory  perception  a  hallucination  ap- 
pears in  the  sexual  organs. 

In  the  great  majority  of  cases  the  sense  deceptions  are 
accompanied  by  disagreeable  feelings,  as  has  already  been  men- 
tioned in  the  deceptions  of  the  taste  and  the  smell,  often,  in  their 


18  General  Symptomatology. 


beginning,  by  anxiety  and  terror  from  the  unaccustomed,  un- 
lieard-of,  horrible  phenomena  (later  the  jiatient  becomes  accus- 
tomed to  tliem).  It  is  seldom  that  pleasurable  feelings  with 
vivid  expectation  accompany  hallucinations  (hysteric  psychoses, 
paretics,  paranoiacs). 

Physiological  rathology  of  the  Hallucinations. 

The  theory  regarding  the  point  of  origin  of  the  hallucina- 
tions is  that  it  resides  now  in  the  peripheral  nerve  apparatus 
(Calmeil,  Foville,  Johannes  Mliller),  now  in  the  thalamus  opti- 
cus (Luys,  Ritti),  the  subcortical  ganglia  (Meynert),  in  the  corti- 
cal sense  centers  (Ferrier,  Tamburini),  sometimes  in  the  con- 
ception center  (Esquirol:  Hallucinations  are  images,  ideas 
which  are  reproduced  h\  the  memory,  associated  with  the  power 
of  imagination,  personified  through  custom  or  habit). 

Opposed  to  their  peri2:)heral  origin  (including  that  from  the 
subcortical  centers),  is  the  fact  that,  although  the  peripheral 
apparatus  may  be  entirely  destroyed,  as  in  the  blind  and  deaf, 
the  hallucinations  will  continue  to  develop  or  persist  in  these 
senses;  that,  further,  the  nerve  in  peripheral  excitation  answers 
only  with  a  phenomenon  corresponding  to  its  specific  function 
(the  optic  nerve,  lightning;  the  acoustic,  roaring,  crashing), 
not  with  composite  sense  images;  the  origin  from  the  imagina- 
tion is  contradicted  by  the  appearance  of  unilateral  hallucinations 
and  with  a  purport  which  is  foreign  to  the  whole  course  of 
thought,  as  this  is  observed,  especially  in  the  beginning  of  single 
psychic  diseases,  and  particidarly  in  paranoia  hallucinatoria. 

On  the  other  side  is  the  fact  that  the  mentally  unbalanced 
firmly  believe  in  tlie  real  truth  of  their  hallucinations,  that  their 
thought  and  action  are  conformable  to  them,  that  the  deceptions 
cannot  be  corrected,  that  the  hallucinations  generally  take  their 
cue  from  delusions  or  are  adapted  to  them,  not  to  be  understood 
without  the  assumption  of  a  contemporaneous  pathological 
change  of  the  psyche. 

Opposed  to  the  origin  of  hallucinations  in  the  special  corti- 
cal sense  centers  are  those  observations  in  which  focal  diseases  of 
these  centers  did  not  lead  to  complicated  hallucinations,  but  only 
to  visual  phenomena,  or  the  perception  of  noises  (Gowers,  Ben- 
nett). 


Hallucinations.  19 


If  the  hallucination  was  only  a  focal  affection  of  the  cor- 
responding sense  center,  the  patient  would  be  able  to  recognize 
the  delusion  through  the  control  of  the  sense  perceptions  which 
had  remained  normal,  which  is  really  the  case,  the  hallucina- 
tions being  recognized  as  deceptions  (hallucinations  avec  con- 
science). On  the  contrary,  the  actual  participation  of  the  sense 
centers  in  the  hallucination  is  demonstrated  by  the  change  of  the 
hallucinated  image  corresponding  to  the  disturbed  sense  center. 
(Hallucinations  of  hearing  in  an  atactic-aphasic  with  word- 
deafness  as  unintelligible  phrases  with  the  substitution  of  foreign 
words  [Holland],  hallucinations  of  sight  in  a  patient  with  cen- 
tral limited  defect  of  the  field  of  vision;  corresponding  to  the 
defect,  the  hallucinations  showed  only  parts  of  the  hallucinated 
objects,  only  the  head  or  breast  [Pick].) 

In  this  condition  of  things  the  psyclio-sensorial  theory  of 
hallucinations  in  those  mentally  diseased  appears  to  be  the  only 
one  which  corresponds  to  the  facts.^  The  hallucination  has  as 
a  preliminary  condition  a  pathological  change  of  the  psyche, 
on  whose  basis  and  with  whose  participation  the  pathological 
stimulus  of  the  sense  centers  produces  the  hallucination.  From 
this,  the  hallucination  represents  a  focal  symptom  in  the  diffuse 
disturbance  of  the  hrain  cortex,  and  is  a  local  sign  of  the  disease 
according  to  the  situation  of  the  center  attacked. 

That  an  excitation  coming  from  the  periphery  may  be  of  sig- 
nificance for  the  calling  forth  of  hallucinations,  has  been  proved 
in  the  discussion  of  illusions.  This  peripheral  irritation  may 
also  be  induced  artificially. 

The  cessation  of  the  peripheral  irritation,  closing  of  the 
eyes,  stopping  up  the  ears,  removal  of  the  pathological  condition 
in  the  terminal  apparatus  of  a  special  sense  may  diminish  the 
intensity  of  the  hallucination,  or  even  cause  its  disappearance. 

Occurrence  of  Hallucinations. 

The  appearance  of  hallucinations  premises  that  the  indi- 
vidual has  taken  up  sense  images  in  the  cortical  center  in  which 
there  are  hallucinations.     A  person  blind  or  deaf  from  birth 


^  (Storch,  Versuch  einer  psycho-physiologische  Daitstellung  der  Sin- 
neswahrnehmungen.     Monatschiift  fiir  Psychiatrie,   1902. 


20  General  Symptomatology. 

cannot  hallucinate  in  the  visual  or  auditory  senseS;,but  he  who  has 
become  blind  or  deaf  may  do  this : 
Hallucinations  are  observed: 

1.  In  persons  of  normal  mind,  isolated,  or  with  long  inter- 
vals only,  in  the  sense  of  vision.  (Goethe,  Spinoza,  Xapoleon — 
tlie  latter,  according  to  the  account  of  Thierry,  at  important 
junctures  saw  a  star  above  him,  which  beckoned  him  forward). 
Further,  see  the  interesting  communications  of  Jolly  on  the  hal- 
lucinations of  sight  of  the  botanist  Nageli,  who  had  suffered 
from  both  eyes  being  burnt  (Zeitschrift  fiir  Psychiatric,  Vol.  40, 
])age  GS-i). 

Sometimes  hallucinations  of  vision  appear  in  the  dark 
chamber  after  operations  for  cataract^  in  individuals  who  are 
otherwise  healthy. 

2.  In  liystcria  and  epilepsy.  The  patient  is  at  first  doubtful 
whether  the  hallucinated  sense  perception  is  true  or  not,  vet  he 
soon  persuades  himself  that  he  has  been  deceived,  and  complains 
then  of  the  "abnormal"  appearances. 

In  epilepsy,  hallucinations  appear,  especially  in  the  sense  of 
smell;  sometimes  they  form  the  aura,  sometimes  an  epileptic 
equivalent.  In  epileptics,  one  may  sometimes  call  forth  hallu- 
cinations of  vision  by  compression  of  the  carotids. 

3.  In  anemic  states  of  the  hraiji  after  the  loss  of  much  blood, 
especially  after  parturition,  in  the  puerperium,  also  with  the  ship- 
wrecked. 

Hallucinations  appear  preferably  in  the  sense  of  vision,  but 
also  in  the  sense  of  hearing,  as  the  sound  of  bells  and  the  like. 

On  the  basis  of  anemia  of  the  brain  there  also  arise  the  so- 
called  hypnagogic  hallucinations,  which  appear  on  going  to  sleep 
or  shortly  before  awakening,  sometimes  in  persons  mentally 
normal. 

4.  In  f  eh  rile  diseases;  children,  especially,  become  easily 
hallucinated  as  soon  as  they  become  feverish. 

5.  In  intoxication  and  intoxication  psychoses. 

0.  In  focal  diseases  of  the  cortical  sensoral  sphere,  as, 
for  instance,  in  diseases  of  the  occipital  lobe  hallucinations  of 
vision  appear  with  the  consciousness  that  they  are  deceptions. 

7.  In  the  various  mental  diseases  (see  the  single  forms). 
Hallucinations  seldom  appear  in  idiots;  seldom  (as  hallucinations 


llalluciiKitions.  21 


of  vision)  with  nuuiia,  sporadically  in  paranoia  simplex,  more 
frequently  as  hallucinations  of  hearin<;-,  Imt  in  other  senses  also 
with  melancholia.  In  delirium  hallucinatorium,  as  in  paranoia 
hallucinatoria,  the  hallucinations  form  an  essential  constituent 
of  the  type  of  the  disease,  just  as  the  hallucinations  of  the 
coenesthctic  sense  do  in  all  hypochondric  forms  of  the  various 
psychoses. 

In  the  twilight  states  (which  see)  hallucinations  appear  as 
in  physiological  dreams;  but  here  they  are  really  images  of 
memory,  which,  as  in  a  dream,  are  arbitrarily  confused  and  con- 
nected without  reference  to  space  and  time. 

Sometimes  hallucinations  are  found  in  only  one  sense, 
oftener  in  several,  and  one  often  finds  on  close  examination  that 
the  hallucinations,  which  appear  vividly  only  in  one  or  two 
senses,  in  reality  are  in  all  or  in  almost  all  the  senses. 

8.  After  recovery  from  mental  disease,  hallucinations  may 
long  persist  in  single  senses  with  the  consciousness  of  deception 
(residual  hallucinations — Wernicke).  One  of  my  melancholiacs 
heard  the  word  "sin"  exclaimed  for  more  than  a  year  following 
his  recovery. 

Diagnosis. — To  determine  that  a  hallucination  exists,  it  is 
necessary  to  show  that  sensorial  perception  is  present.  It  is 
necessary  to  eliminate  from  the  patient's  description  of  his  ap- 
parent hallucinations  all  that  may  be  considered  as  new  interpre- 
tation (elaboration  by  his  system  of  mania)  or  attempts  at  ex- 
planation, and  ascertain  what  he  is  persuaded  that  he  has 
perceived. 

By  this  the  hallucinations  will  present  a  more  or  less  vivid 
sense  image,  which  will  be  specially  prominent  by  the  insistence 
of  the  patient.  The  hallucination  of  one  mentally  diseased  is 
characterized  further  by  the  persistency,  by  the  force  of  convic- 
tion with  which  the  patient  presents  the  subjective  perception  as 
an  objective  fact.  In  the  beginning  of  the  psychosis,  however, 
the  patient  is  still  somewhat  doubtful ;  he  attempts  by  the  con- 
trol of  the  other  senses  to  convince  himself  whether  some  one  has 
really  spoken,  or  whether  it  is  deception.  Gradually  he  does  not 
use  this  control. .  He  is  convinced  that  it  is  true,  and  completes 
the  ph^'sical  impossibility  by  tbe  wonders  of  wireless  telegraphy, 
of  the  telephone,  of  the  phonograph,  the  Roentgen  rays,  magnet- 


22  General  Symptomatology. 

ism  or  "enchantment/"  'Vitchcraft."  Against  all  objections  he 
clings  to  his  standpoint,  and  sometimes  justifies  it  by  the  superi- 
ority of  his  senses.  "Formerly  I  heard  it  as  you  do,  but  now  my 
hearing  is  more  acute,"  said  one  of  my  patients  when  I  said  that 
I  did  not  hear  the  "voice"  which  he  had  just  heard. 

In  many  cases,  however,  the  patients  recognize  their  hallu- 
cinations as  deceptions.  They  view  them  as  in  some  measure  o1> 
jective,  observe  them  and  declare  them  to  be  the  machinations 
of  certain  persons,  attempts  of  their  enemies  who  wish  to  injure 
them  or  even  to  make  them  "crazy"  (alcoholists,  paranoia  hallu- 
cinatoria). 

Hallucinations  may  be  confounded  with : 

1.  Psychic  haUucinations  (Baillarger),  intellectual  hallu- 
cinations.— It  concerns  here  only  ideas  of  greater  vividness ;  there 
are  "words  without  sound,"  "pictures  without  color:"  "it  seems 
as  if  I  see,"  "it  seems  as  if  an  inner  voice  said  that  to  me."  There 
is,  however,  really  nothing  seen  or  heard.  In  this  category  be- 
long, also,  the  false  interpretation  of  sense  perceptions,  objectively 
correct.  The  patient  hears  the  actual  rattling  of  the  key  in  the 
bunch  of  keys,  and  says  that  he  hears  the  clanking  of  chains,  with 
which  he  is  to  be  fettered. 

2.  Paramnesia. — The  patient  says  this  or  that  person  has 
been  present,  he  has  experienced  this  or  that.  This  may  come 
from  a  hallucination  which  has  been  present,  but  is  often,  espe- 
cially in  states  of  mental  weakness  (paresis,  dementia  senilis), 
the  product  of  a  paramnesia  (which  see). 

3.  Symholization. — As  children  in  play  give  all  sorts  of  per- 
sonifications and  meaning  to  their  plaji-hings,  so  also  the  men- 
tally weak  patient  symbolizes  the  persons  and  things  of  his  en- 
vironment, without  there  being  any  disturbance  of  the  sense 
perception. 

In  like  manner  paranoiacs,  especially,  transform  their  en- 
vironments according  to  the  dominant  system  of  mania,  even 
without  hallucinations  or  illusions  (delirium  palingnosticum  and 
metabolicum). 

Dissimulation  of  HaUucinations. 
\\  ith  tlie  object  of  not  being  taken  to  an  institution,  or  to 
be  discharged  from  one,  or  to  avoid  being  put  under  le^al  re- 


IlaUucinaUuns.  28 


straint,  those  mcntrtlly  diseased  !-oinctimes  conceal  tlicir  hallucina- 
tions. One  often  succeeds  in  finding  out  the  actual  situation  by 
observing  the  changing  expression  of  the  countenance,  the  move- 
ments of  the  head,  by  asking  why  they  look  at  the  table-cloth,  at 
the  door,  why  they  have  stopped  up  their  ears  with  cotton,  the 
keyhole  with  paper;  the  patient  is  confused  at  first  and  delays 
liis  answer,  but  gradually  betrays  himself.  Sometimes  the  writ- 
ten memoranda  of  the  patient,  which  have  been  found  before,  h'.s 
l)ehavior  when  he  thinks  himself  alone  and.  unobserved,  estab- 
lish the  certainty  of  the  diagnosis. 


Significance  of  the  Hallucinations  for  Action. 

The  convincing  power  of  the  hallucinations  explains  their 
influence  on  the  endeavors  and  the  existing  anomaly  of  thought, 
their  transformation  into  actions  without  the  essential  inter- 
lacing of  inhibiting  ideas. 

Sometimes,  especially  in  cases  of  marked  obscuring  of  the 
consciousness,  the  hallucinated  are  so  occupied  with  their  hallu- 
cinations, which  have  created  a  new  sensory  world  for  them,  that 
they  seem  entirely  oblivious  to  all  other  occurrences  in  their 
surroundings;  in  other  cases  their  entire  action  and  leisure, 
whether  excited  or  at  rest,  is  really  determined  by  hallucinations ; 
more  often  certain  hallucinations  give  the  action  a  determined 
direction,  sometimes  inciting  to. acts  of  violence. 

God  commands  the  patient  to  bring  him  an  offering,  and  the 
patient  kills  a  strange  man;  God  commands  him  to  cleanse  the 
church  of  unworthy  priests,  and  the  patient  sets  fire  to  the  cathe- 
dral (of  York).  Now  and  then,  on  the  footsteps  of  the  hallu- 
cination, follows  a  powerful  reaction. 

The  patient  hears  an  oath  from  his  companion  or  from  a 
stranger  on  the  street,  and  he  immediately  strikes  the  man  by 
whom  he  thinks  it  was  uttered. 

With  the  weakening  of  the  intelligence  and  energy  the 
power  of  the  hallucinations  over  his  actions  weakens  also. 

The  prognosis  of  the  hallucinations  depends  upon  the  basic 
disease;  those  which  are  connected  with  a  systematized  mania 
have  an  unfavoral)le  prognosis. 

The  treatment  of  hallucinations  should  first  consider  the 
form  of  the  psychosis  from  which  they  have  originated. 


24  General  Symptomatology. 

According  to  the  above  statements  it  is  important  to  examine 
carefully  the  j^eripheral  apparatus  of  the  sensory  organs  wliich 
are  hallucinated. 

By  treatment  of  the  pathological  changes  which,  perhaps, 
are  there  present,  it  is  sometimes  possible  to  exert  a  favorable 
influence  to  dispel  or  decrease  the  hallucinations. 

According  to  the  symptoms,  one  may  use  extr.  stramonii  0.1, 
increasing  to  0.25  gram  once  or  twice  daily,  also  arsenic  in  in- 
creasing doses. 

Attempts  to  convince  the  patient  of  the  imreality  of  the 
objective  presence  of  the  objects  of  his  hallucinated  sense  percep- 
tions are  useless,  and  often  excite  the  patient. 

But,  just  as  little,  ought  one  to  concede  the  real  truth  of  his 
hallucinations.  One  should  explain  to  the  patient,  as  far  as  he 
is  amenable  to  explanation,  calmly  and  determinedly,  that  an 
excited  fancy  may  show  to  him  many  things  which  do  not  really 
exist. 


4.  Hypesthesia  and  Anesthesia  of  the  Sense  Perception. 

The  jiathological  diminution  in  the  activity  of  the  sense 
perception  may  show  itself  as  a  condition  of  delayed  conduction. 

This  may  be  present  in  the  entire  sensory  apparatus,  or  ap- 
pear only  in  single  senses. 

This  accompanies  the  organic  diseases  of  the  brain  (paresis, 
dementia  senilis),  is  often  present  in  the  secondary  weak  states 
of  dementia,  but  appears  also  in  functional  psychoses,  especially 
in  melancholia.  It  lasts  a  certain  time  before  the  impression  on 
the  sight  or  hearing  leads  to  identification. 

Hypesthesia  or  anesthesia  in  the  sense  of  vision  shows  itself 
in  the  complaints  of  the  patient  that  all  is  dark  and  gloomy,  that 
he  cannot  see  men  or  houses  distinctly,  that  they  seem  strange; 
the  highest  degree  of  anesthesia  forms  soul-blindness,  in  Avhich 
it  is  impossible  to  identify  the  things  seen  with  former  similar 
sight  impressions,  that  is,  to  recognize  them  again. 

In  the  sense  of  liearing  the  corresponding  phenomena  mani- 
fest themselves  to  the  degree  of  soul-deafness.  In  the  sense  of 
smell  or  taste  centrally  conditioned  anosmia  or  ageusia  appears. 


Didurhanccs  of  Thought.  25 


which,  in  dementia,  paresis,  and  similar  states,  makes  possible 
occupation  with  the  most  disgusting  things,  and  even  the  eating 
of  them. 

In  the  sense  of  touch  anesthesia  manifests  itself  as  a  loss  of 
the  sensation  of  being  touched,  of  the  sense  of  temperature  (in- 
sensibility of  the  demented,  raving,  and  paretics  to  heat  and 
cold). 

In  the  hinesthetic  feelings  the  anesthesia  appears  especially 
as  a  loss  of  the  feeling  of  fatigue  (in  raving  and  paralytic 
mania). 

With  the  loss  of  tlie  coenesthetic  sense  is  connected  the  idea 
that  single  limbs  have  died,  that  the  Avhole  body  is  dead. 

Even  though  a  lasting,  often  progressive,  hypesthesia  and 
anesthesia  of  the  sensory  centers  accompany  the  various  forms  of 
organically  conditioned  dementia,  they  may  also  appear  only 
transiently,  especially  with  the  hysteric  and  epileptic  psychoses, 
with  melancholia,  here  often  changing  or  contemporary  with 
states  of  hyperesthesia  in  the  same  or  other  sense  centers  (anes- 
thesia dolorosa),  often  in  all  states  of  clouding  of  the  con- 
sciousness. 

Since  a  certain  degree  of  irritation  of  the  sense  centers  is 
necessary  to  assure  the  possibility  of  rejjroduction,  it  is  self-ex- 
planatory that  in  all  conditions  where  there  is  a  hypesthesia  or 
anesthesia  of  the  sense  centers,  the  irritations  of  the- senses  which 
have  been  present  during  this  condition  cannot  be  reproduced. 

The  patients  lose  the  capability  of  impression,  that  is,  the 
power  of  impressing  anything  upon  the  memory;  they  cannot 
acquire  new  memory  images  and,  consequently,  new  ideas.  They 
cannot  reproduce  what  has  just  happened  (especially  common  in 
dementia  senilis  and  in  the  later  stages  of  paresis). 

II.  THE  DISTURBANCES  OF   THOUGHT. 

The  association  of  the  ideas  may  be  disturbed  pathologi- 
cally when : 

1.  Certain  ideas  press  forward  with  especial  power,  or  one 
or  another  law  of  association  gains  a  supremacy  over  the  others 
— imperative  concepts. 


26  General  Symptomatology. 

2.  An  immoderate  heightening  of  the  speed  of  the  efflux  of 
the  associations  appears. 

3.  Ideas  wliich,  according  to  the  laws  of  associations,  should 
not  be  connected,  are  connected  with  one  another  (disturljance 
of  the  coordination  of  the  associations,  delusions). 

■i.  The  associations  are  perfected  too  slowly  or  too  feebly. 


1.  Imperative  Concepts. 

These  will  be  discussed  in  the  chapters  on  special  psychiatry 
as  paranoia  rudimentaria. 

2.  Pathological  Heightening   of  the  Rapidity  of 
Associations. 

Although  hitherto  experimental  researches  on  the  insane 
have  given  contradictory  results  (Maria  TValitzkaja  found  in 
maniacal  patients  one-half  to  one-third  the  ordinary  duration  of 
the  time  of  association — Kraepelin,  on  the  contrary,  retardation 
in  the  same  psychic  condition — ^while  in  normal  states  the  time 
of  association,  roughly  stated,  that  is,  the  time  from  speaking 
the  incicing  word  to  the  pronouncing  of  the  associated  word,  is 
one-half  to  one  second  and  more),  nevertheless  clinical  observa- 
tion, especially  the  fact  that  such  j^atients  reproduce  vividly 
memor5'-images,  and  can  associate  what  was  obscure  for  them  in 
health,  speaks  for  a  heightened  activity  of  the  associations. 

The  accelerated  efflux,  which  may  increase  to  flight  of  ideas, 
is  an  essential  symptom  of  mania  (see  this  latter).  In  combina- 
tion with  heightened  excitability  and  excitement  of  the  psycho- 
motor centers,  they  constitute  that  flight  of  ideas  which  is  the 
essence  of  maniacal  raving. 

These  conditions  of  the  accelerated  efflux  of  the  ideas  may 
ajDpear  intercurrently  with  maniacal  excitements  in  the  most 
diverse  psychoses ;  they  quite  often  form  phases  of  a  psychosis, 
as  in  circular  psychosis,  in  the  course  of  the  katatonic  symptom- 
complex,  of  paresis,  of  Imteric  and  epileptic  psychoses. 

Finally,  many  intoxication  psychoses  run  under  the  type  of 
maniacal  excitation  or  maniacal  raving  (alcohol  and  other  in- 
toxications) . 


Dchisions.  27 

3.  Delusions.^ 

By  delusions  are  designated  jwlgmenis  and  conclusions 
irldch  arise  from  a  pathological  association  of  ideas,  involving 
the  Ego,  not  recognized  as  pathological  and  not  susceptible  of 
correction  by  counterarguments. 

The  content  of  delusions  is  different  according  to  age  and 
sex,  environment  and  education,  the  position  of  the  patients  in 
society  and  their  aspirations,  and  with  the  diversity  of  social, 
religious,  and  political  relations. 

However  different  the  manner  of  expression  of  delusions 
may  be,  there  are  certain  "primordial  deliria"  which  may  be  dis- 
tinguished, as  Griesinger  has  pointed  out. 

(a)   Expansive  Delusion  (Delirium  Manicum). 

The  lower  degrees  of  egotism,  as  they  appear  childishly  in 
imbeciles  and  the  demented,  are  developed  to  megalomania  in 
maniacai  conditions,  and  to  efflorescent  megalomania  (delusions 
of  grandeur),  especially  in  paresis. 

Megalomania  may  refer: 

1.  To  the  social  standing  of  the  patient.  The  patient  thinks 
he  is  Minister,  Field  Marshal,  Kaiser,  "Kaiser  of  the  pleasure- 
grounds,"  "Euler  of  the  whole  world,"  "Jesus  Christ,"  "God, 
actually  or  to  be  Over-God."  He  has  4000  omnibuses,  and 
20,000  carriages,  all  orders,  millions,  unnumbered  milliards. 
Women  boast  about  their  toilets,  their  jewelry,  are  Crown  Prin- 
cesses, Princesses  of  the  World,  Empresses. 

2.  To  the  intellectual  qualities.  The  patient  understands 
and  speaks  all  languages,  has  made  the  greatest  discoveries  (per- 
petuum  mobile),  builds  a  railroad  to  the  moon,  is  the  greatest 
scholar. 

3.  To  the  bodily  capabilities.  The  patient  has  peculiar 
Ijodily  endowments,  raises  1000  centners  with  the  little  finger,  has 
a  penis  3  meters  long,  and  begets  a  child  every  minute,  women 
have  borne  500  children,  are  again  pregnant  although  they  have 
long  passed  the  climacteric. 

In  paresis  the  grandiose  ideas  often  extend  in  all  directions, 
and  these  patients  show  by  their  manner  and  appearances  that 


^  Friedmann,  On  Delusions.    Wiesbaden,  1894. 


28  General  Symptomatology. 

they  are  weak-minded ;  while  in  mania  they  generally  keep  within 
certain  limits.  In  the  hysteric  psychosis  the  megalomaniacal 
ideas  often  show  themselves  on  the  erotic  side  (men  of  high  posi- 
tion have  fallen  in  love  with  the  patient),  sometimes  as  religious 
mania  (resurrections)  ;  in  epileptic  and  alcoholic  psychoses  the 
religious  idea  is  also  often  met  ("God-pardoned/'  "prophet")  ; 
in  paranoia  megalomaniacal  ideas  develop  in  the  most  diverse  di- 
rections. Here  they  appear  at  first  logically  formed  by  the  medi- 
tation of  the  patient  (see  paranoia).  Transient  and  changing 
megalomaniacal  ideas  also  appear  in  delirium  hallucinatorium, 
in  a  less  degree  in  the  maniacal  phases  of  circular  psychoses. 

(b)   Depressive  Delusions. 

1.  Melancholic  Delusions.  ' 

These  arise  on  the  basis  of  depressive  moods  and  anxiety. 

The  patient  thinks  that  he  has  not  done  his  duty  to  God  and 
man,  he  has  sinned  (delusion  of  transgression),  he  has  perjured 
himself,  he  has  betrayed  his  country,  stolen,  committed  adultery, 
he  must  suffer  horrible  punishments  not  only  in  the  hereafter, 
but  also  on  earth.  All  the  evil  in  the  world  proceeds  from  him, 
whoever  associates  with  him  will  be  damned,  he  draws  everyone 
into  destruction  by  his  exhalations,  even  by  his  words  (delirium 
divergens). 

If  these  delusions  appear  especially  exaggerated,  as  in  efflor- 
escent megalomania,  but  in  an  opposite  direction  ("I  will  serve 
1000  years  in  the  penitentiar}',"  "I  have  ruined  millions  of 
men"),  we  speak  of  micromania. 

Single  actual  occurrences  in  the  life  of  the  patient,  even  his 
whole  past  ("my  whole  life  was  a  pool  of  transgression"),  are 
retrospectively  elaborated  in  the  sense  of  melancholic  mania : 
these  patients  never  become  tired  of  self-accusation. 

As  a  logical  consequence  the  delusion  of  persecution  of  the 
melancholiac  develops. 

At  first  the  patient  sees  in  the  looks  of  his  guardians,  in 
their  peculiar  movements,  in  the  expectoration  or  the  turning 
away  of  the  faces  of  persons  passing  in  the  street  (attention  or  re- 
lation mania  brought  about  by  illusions  or  new  interpretations), 
the  signs  that  people  have  discovered  his  shameful  deeds.     Later 


Delusions.  29 


the  patient  is  convinced  that  tlu'  police  arc  tracing  him,  pursue 
liim  (in  antiquity  the  Furies  played  this  role,  in  the  Middle  Ages 
the  witches),  that  they  come  to  put  him  in  prison,  to  fetter  him. 

The  devil  takes  possession  of  the  patients  (de mono-melan- 
cholia), they  expect  the  day  of  judgment. 

They  fear  punishment,  and  yet  it  appears  just  to  them  on 
account  of  all  their  misdeeds. 

2.  Ilypochondro-melanchoUc  Delusions. 

Self-condemnation  and  the  delusion  of  transgression  are  con- 
nected with  the  condition  of  one's  own  body  and  are  generally  con- 
nected with  hallucinations  and  illusions  of  the  coenesthetic  sense. 

Even  here  at  first  the  attention-mania  appears  quite  often; 
the  people  in  the  street  see  that  the  patient  masturbates;  they 
point  at  a  node  on  his  face  which  denotes  syphilis.  They  say 
further  that  onanism,  an  actual  or  supposed  syphilitic  infection 
has  ruined  his  whole  body,  destroyed  his  mind,  "I  must  rot  in  my 
living  body,''  "my  testicles,  my  penis  are  withered." 

In  other  cases  the  patients  consider  the  change  in  their 
bodies  as  a  just  punishment  of  God  for  the  sins  which  they  have 
committed,  as  the  consequence  of  poisons  which  were  adminis- 
tered to  them  while  eating,  or  otherwise,  on  account  of  their 
misdeeds. 

Even  here  an  anxious  delirium  divergens  appears  quite  often ; 
the  patients  carefully  avoid  touching  others,  will  not  sit  on  a 
chair  or  in  the  closet  for  fear  of  bringing  others  to  ruin  by 
contagion. 

In  the  highest  degree  of  these  hypochondric  delusions  they 
generally  progress,  with  hallucinations  in  the  various  senses, 
as  far  as  delusions  of  metamorphosis ;  the  patients  believe  that 
they  are  changed  by  divine  punishment  into  dogs  (cynanthropy), 
wolves  (lycanthropy),  a  sort  of  delusion  which,  contrary  to  the 
experience  of  the  Middle  Ages,  is  now  very  rare. 

The  hypochondro-melancholic  mania  appears,  besides  being 
in  melancholia  hypochondriaca,  where  it  is  purest,  also  tran- 
siently in  delirium  hallucinatorium,  further,  in  epileptic  psy- 
choses, more  rarely  in  intoxication  psychoses,  especially  in  alco- 
holism, quite  often  in  the  depressive  stage  of  paresis. 

Both  kinds  of  depressive  delusions  are  connected  witli  the 


30  General  Symptomatology. 

clinical  t}T)es  of  melancholia  generalis.  They  sometimes  lead  to 
the  type  of  stujior  (anxious  stupor)  with  very  vivid  anxious  hal- 
lucinations of  vision  and  audition. 

(c)   The  Paranoic  Delusions  of  Persecution. 

At  first  and  in  the  mildest  form  these  appear  as  attention 
(Xeisser)  or  relation  delusions.  There  is  a  special  immediate 
relation  to  himself  for  -ndiat  passes  near  him  on  the  street,  or  for 
what  may  he  in  the  newspapers,  and  to  this  is  added  a  detractive, 
injurious  significance  (delirium  convergens).  The  emotion  of 
tense  expectation  (Linke)  which  generalh"  accompanies  this  de- 
lusion, especially  at  the  beginning  of  the  disease,  supports  its  ex- 
pansion and  confirmation.  This  expectation,  that  something  will 
"liappen"'  again,  makes  the  patient  restless,  unstable,  and  dis- 
trustful. 

Illusions  and  hallucinations  often  cooperate  for  making  it 
^more  intense  or  to  develop  it. 

Gradually,  also,  the  past  becomes  pathologically  transformed 
to  correspond  with  the  momentarj^  perceptions. 

The  paranoic  delusion  of  persecution  is  developed  from 'the 
attention  and  relation  delusion. 

The  patient,  only  distrustful  and  doubtful  at  first,  becomes 
gradually  convinced  that  he  is  the  victim  of  persecutions  and,  in 
contrast  to  the  delusion  of  persecution  of  the  self -accusing  mel- 
ancholiac,  the  persecuted,  paranoiac  considers  himself  the  inno- 
cent victim  of  his  persecutor.  The  sufferings,  which  are  brought 
upon  him  b}^  persecution,  are  not  the  punishment  for  misdeeds 
or  sins  committed;  they  have  proceeded  rather  from  false  accu- 
sations, from  en^y  and  the  spirit  of  revenge  of  his  enemies,  per- 
haps, also,  because  his  foes  wish  to  shelter  themselves  from 
punishment. 

Sometimes  there  are  enemies  acting  singly  and  individually, 
sometimes  they  act  in  groups,  parties  ('^social  democrats,"  "an- 
archists," "illuminated,"  "free-masons"),  sometimes  police  ofii- 
cers,  the  minister,  the  sovereign. 

Since  the  patient  places  a  special  value  upon  his  person,  and 
such  extraordinary  means  are  taken  to  wage  war  upon  it,  an 
over-estimation  of  himself  is  soon  developed,  which  finally  leads 
to  megalomania.     Some  one  injures  him,  confines  him,  will  an- 


Delusions.  31 


niliilalo  liiin  si)iri(ii;illy,  will  make  liiin  dead  in  law  or  destroy 
him  altogether;  in  order  to  liindcr  him,  take  from  liim  tlie  posi- 
tion due  to  his  birth  in  soeiet}^  in  the  state  or  in  the  chureli ;  his 
gifts  or  his  god-like  insj)iration. 

The  multiform  delusions  are  here  bound  into  a  system. 

There  may  also  be  a  fusion  of  depressive  delusions  of  self- 
accusation  with  paranoic  delusions  which  express  themselves  in 
about  the  following  manner: 

"It  is  true  that  here  and  there  I  have  not  done  right,  but 
the  cruelty  and  duration  of  the  punishment  which  I  have  suffered 
by  i^ersecution  stand  in  no  j^roportion  to  that  insignificant  fault, 
Avhich  is  already  sufficiently  punished/' 

Paranoic  delusions  of  23ersecution  appear,  besides  being  pres- 
ent in  paranoia,  especially  in  imbecility,  in  hysteric  and  epileptic 
psychoses,  in  the  varied  intoxication  psychoses,  especially  in  al- 
coholism, in  paresis,  and  in  senile  dementia. 

They  are  quite  often  present  transiently,  especially  in  the 
mild  form  of  attention  delusion,  in  those  predisposed  through 
heredity,  without  coming  to  a  developed  psychosis,  appearing 
especially  at  the  time  of  puberty  and  in  the  climacteric. 

On  account  of  its  practical  interest  we  cite  a  peculiar  form 
of  paranoic  delusion  which  is  designated  as  the  delusion  of  jeal- 
ousy.^ Either  one  of  a  married  couple  observes  in  the  other  that 
he  or  she  exchanges  glances  with  those  in  the  house  or  on  the 
street ;  the  same  person  appears  in  the  theater  or  on  the  railroad ; 
the  journals  have  significant  cipher  dispatches.  Illusions,  and 
hallucinations  of  taste,  smell,  or  in  the  coenesthetic  sense  (ideas 
of  being  poisoned),  may  tend  to  fortify  or  confirm  these  delu- 
sions. 

A  demeanor  of  repulsion  shown  to  the  patient  by  the  hus- 
band or  wife,  denial  of  the  marital  privilege  (especially  by  women 
towards  alcoholistic  husbands,  paralytics,  or  husbands  who  have 
become  odious  through  mental  disease)  supports  and  strengthens 
the  delusion  of  jealousy. 

Sometimes  the  jealousy  may  not  be  without  ground  in  fact, 
and  yet  we  must  assume  a  delusion  of  jealousy  when  the  idea  has 
gained  so  dominant  an  expansion  that  it  rules  exclusively  the 


^Villiers.     Le  delire  de  la  jalousie.     Brussels,  1899.     Schiller,  Eifer- 
suchtwahn  bei  Frauen,  Jahrbuch  fiir  Fsychiatrie.  1901. 


32  General  Symptomatology. 


entire  consciousness,  so  that  all  events  are  interpreted  by  that, 
and  especially  Avhen  violent  actions  toward  the  other  are  prompted 
by  such  feelings. 

The  delusion  of  jealousy  appears  in  men,  except  in  para- 
noiacs,  especially  in  alcoholists  and  the  various  other  intoxica- 
tion ps3'choses  (cocainism,  diabetes),  further,  in  imbecility,  in 
paretics,  especially  in  its  initial  stages,  in  senile  dementia,  some- 
times in  psychoses  after  apoplectic  attacks;  it  is  observed  in 
women,  besides  being  in  the  conditions  mentioned,  especially 
in  hysteric  and  alcoholic  psychoses,  at  the  climacteric  (where 
the  realization  of  the  disappearance  of  their  charms  acts  as 
auxiliary),  in  lactation. 

The  paranoic  delusion  of  p-cxsecution  becomes  quite  often 
the  point  of  departure  for  certain  actions  of  the  patients:  the 
persecuted  become  the  persecutors  of  their  enemies  (persecutes 
persecuteurs). 

A  particularly  common  example  of  this  kind  of  patients  is 
offered  by  the  querulants.  Believing  themselves  injured  by 
police  regulations  or  judicial  sentence,  they  become  untiring 
combatants  in  speech  and  writing  for  their  inherent  rights. 

The  paranoic  idea  of  being  injured  by  unjust  civil  or 
criminal  legislation  and  the  complaints  arising  on  the  basis  of 
mania  appear,  besides  being  in  paranoia,  in  imbeciles,  sometim-.^s 
in  the  incipient  stages  of  senile  dementia,  further,  in  alcoholists, 
in  morphinists,  and  also  in  epileptics.  Every  querulant,  how- 
ever, is  not  mentally  diseased. 

On  the  basis  of  depressive  and  paranoic  delusions  sometimes 
arise 

(d)   Delusions  of  Negation. 

(Delire  des  negations,  Cotard.) 

These  may  lefer  to  : 

1.  One's  own  person :  '"I  am  no  longer  a  man,  I  have  no 
heart,  no  longer  sexual  organs,  because  I  cursed  God  (melan- 
cholic mania  of  transgression),  because  I  have  ruined  myself 
by  my  dissipated  life  (melancholo-h^-pochrondriac),  because 
my  enemies  have  poisoned  me.  have  destroyed  me  by  electricity" 
(paranoiac).     "I  shall  never  have  stools  again,  for  a  stone  'is 


Delusions.  33 

lying  before  my  anus."     This  last  utterance  is  found,  in  the 
most  diverse  conditions. 

The  hypochondriac  designates  the  obstruction  as  a  stone 
only  figuratively,  the  melancholiac  has  the  hallucination  in  the 
coenesthetic  sense,  which  deceives  him  so  that  be  tbinks  tbere 
is  a  stone  there  for  the  punishment  of  his  past  sins  (purely 
mclancbolic)  or  the  consequence  of  bis  dissipated  life  (bypo- 
chondro-melancholic,  tbe  paranoiac  considers  tbe  stone  form- 
ation as  the  consequence  oF  poisoning  to  wbich  he  has  been 
exposed.  The  bypochondriac  paretic  designates  the  stone, 
which  makes  defecation  at  times  impossible,  as  a  "stone  of 
marble"  (connection  with  exaggerated  ideas). 

2.  The  external  ivorld.  "There  is  no  God,  no  sun." 
"There  is  no  water,  no  money,  no  eating  any  longer."  "There 
are  no  houses,  no  streets,  everything  is  dead."  With  this,  espe- 
cially in  connection  with  religious  depressive  delusions,  the  idea 
may  arise  that  the  patient  considers  himself  as  the  only  sur- 
vivor, the  "Wandering  Jew." 

Delusions  of  negation  appear  in  melancholia  and  paranoia, 
also  in  paresis,  seldom  in  delirium  hallucinatorium  and  senile 
dementia. 

The  mania  quite  often  inspires  actions  or  a  state  of  passivity 
expressed  essentially  in  negativism,  opposition  (folic  d'opposi- 
tion,  Guislain),  refusing  food  and  medicine. 

Quite  often  the  delusion  of  a  general  changed  existence 
(delirium  metabolicum)^  forms  a  transition  to  the  delusion  of 
negation. 

"Everything  is  imitated,"  "everything  is  false,"  "the  date 
is  falsified,"  "those  around  me  are  not  sick,  they  are  only  deter- 
mined to  observe  me,"  "I  am  transformed,"  "the  name  given  me 
is  not  right." 

Even  here  the  melancholic  or  paranoic  origin  is  to  be 
distinguished ;  yet  these  delusions  belong  especially  to  the  para- 
noic series. 

Contradistinguished  from  these  stands  the  delusion  of 
recognition  (delirium  palingnosticum). 

The  patient  sees  in  those  around  him,  e.g.  in  an  institution 
-*>■ 

'  From /xeTa/3aXXw,  to  transform,  turn  around,  eliange  about. 

3 


34  General  Symptomatology. 

■which  he  has  just  entered,  old  acquaintances  or  persons  whom 
he  knows  by  description  or  pictures. 

In  mania  this  recognition  through  the  aid  of  grandiose 
ideas  takes  place  when,  from  defective  concentration  of  the 
attention,  a  single  mark,  a  wart,  the  fashion  of  the  beard,  or 
even  illusions  of  the  sense  of  vision,  serves  to  designate  persons 
as  acquaintances.  In  j)aresis  and  senile  dementia  the  disturb- 
ance in  the  reproduction  is  the  essential  fault,  since  the  repro- 
duced image,  which  serves  for  comparison  with  the  momentarj- 
sense  imj^ression,  is  so  weak  that  incorrect  identifications  easily 
take  place. 

The  paranoic  forms  of  these  delusions  are  distinguished  by 
this,  that  the  identification  (with  or  without  sense-deceptions) 
occurs  according  to  the  dominant  system  of  mania,  whether  it 
recognizes  in  others  persecutors  or  their  instigators,  or,  accord- 
ing to  megalomania,  eminent  persons  who  wish  to  be  near  the 
patient,  to  serve  him,  or  to  carr}'  out  some  kindred  design. 

In  a  higher  degree,  the  patient,  on  the  basis  of  the  percep- 
tions momentarily  transformed,  identifies  the  entire  situation 
with  one  which  he  has  already  lived  through  in  all  its  details, 
an  identification  which  also  may  take  place  on  the  basis  of  a 
deception  in  the  reproduction   (deception  of  memory). 

Such  states  appear  especially  in  alcoholic  and  epileptic 
mental  diseases. 

The  delusions  described  may  be  connected  in  different  ways 
(romhined  delusions)  ;  a  determined  system  may  be  developed 
from  the  connection  {systematized  delusions)  in  which  the 
various  delusions  are  arranged,  and  interpreted  anew  according 
to  the  true  objective  occurrence;  further,  the  delusions  may 
change  according  to  their  content,  they  may  exist  with  or  with- 
out illusions  or  hallucinations. 

Often,  especially  in  the  depressive  form,  the  delusions  be- 
come monotonous,  returning  in  the  same  form  and  with  the 
same  limited  content. 

Both  in  the  transition  of  the  disease  to  recovery  and  to 
dementia,  the  delusions  fade  away;  they  disappear  without  any 
peculiar  excitation  of  the  feelings,  nor  are  they  in  a  condition 
to  exercise  any  influence  on  the  actions. 

In  contrast  to  this,  the  delusions  in  clouding  of  the  con- 


Deliisions.  35 


sciousness,  especially  in  the  twilight  states,  with  or  without 
hallucinations,  exert  considerable  influence  on  the  actions 
(alcoholic,  hysteric,  epileptic  twilight  states),  and,  without 
disturbances  in  the  emotions  or  anxiety,  become  considerably 
more  intense,  and  by  this  favor  the  carrying  out  of  the  actions 
in  accordance  with  the  system  of  mania  present   (e.g.  suicide). 

After  the  mental  functions  have  become  normal  in  other 
things,  sometimes  there  remain  single,  entirely  limited,  faded- 
out  delusions  (residuary  delusions)  An  the  same  way  as  there 
are  residuary  hallucinations. 

Almost  the  only  time  they  appear  is  on  direct  questioning: 
"There  was  certainly  something  in  it,"  "all  was  not  imagina- 
tion." With  this,  the  otherwise  normal  consciousness  is  in  the 
condition  to  hold  back  the  internal  unrest  and  also  to  suppress 
in  the  bud  an  action  about  to  develop,  perhaps,  from  the  idea 
which  has  remained  behind.  One  may  regard  that  idea  as  a 
scar  which  disfigures  but  does  not  disturb  the  function  of  a  limb. 

It  is  necessary  to  distinguish  from  these  residuary  delu- 
sions the  so-called  fixed  idea.  We  assumed  that  a  mental  dis- 
ease might  consist  entirely  in  a  single  fixed  idea,  and  this 
assumption  had  for  a  partial  basis  the  doctrine  of  monomanias. 
Esquirol  has  already  declared  it :  "If  these  persons  were  not 
mad,  they  would  not  be  monomaniacs." 

A  man,  who  has  only  one  single  delusion  and  the  remaining 
ideas  normal,  should  be  able  to  correct  that,  or,  at  least,  to 
repress  it  the  same  as  with  the  residuary  delusions. 

More  exact  examination  and  observation  of  suitable  cases 
actually  teach,  however,  that  where  only  a  single  delusion 
seems  to  be  present,  a  series  of  others  may  be  demonstrated,  and 
therefore  the  impression  of  "the  only  one"  arises  because  it  is 
especially  prominent. 

We  do  not  know  the  nature  of  the  physio-pathological 
process  which  calls  forth  a  delusion,  any  more  than  we  know  the 
physiological  process  which  produces  an  idea. 

The  peculiar  color,  the  content  of  the  delusion,  may  be  de- 
termined otherwise  than  by  the  above-mentioned  relations : — 

(a)   By  attempts  to  explain  the  pathological  tone  present. 

The  feeling  of  progress,  of  fortune,  which  accompanies  the 
acceleration  of  the  efflux  of  ideas  in  maniacal  states,  becomes 


36  General  Symptomatology. 

expansive;  the  inhibition,  which  is  connected  with  josychic  pain 
and  melancholic  conditions,  gives  their  content  to  depressive 
delusions;  while,  finally,  the  primary  behavior  of  the  external 
world,  experienced  as  inhibiting  and  hostile  to  the  individual, 
impresses  its  mark  on  the  paranoic  mania  of  persecution  in 
paranoia. 

(&)  Occasionally  the  last  occurrences  before  the  attack  of 
the  disease,  oftener  yet  those  occurring  at  the  beginning,  may 
be  decisive  for  the  special  content  of  the  delusions. 

(On  the  unveiling  of  the  respective  memorials  in  Berlin  I 
saw  a  "•'Goethe,'"'  then  a  '"Lessing,"  paranoiacs  who  were  sud- 
denly possessed  by  these  ideas.) 

(c)  Finally,  hallucinations,  dreams,  certain  sensations,  also, 
may  act  upon  the  special  content  of  the  delusions. 

In  respect  to  the  last,  Griesinger  has  already  spoken  of 
"co-ideas"  in  neuralgia,  Schiile  of  "local  signs"  as  the  deter- 
mined content  of  special  localized  neuralgias.  We  have  already 
spoken  of  the  considerable  cooperation  of  illusions  and  halluci- 
nations of  the  coenesthetic  sense  in  creating  the  content  of  the 
delusions. 

Diagnosis. — In  a  number  of  cases  the  monstrosity  of  the 
content  of  the  ideas  confirms  the  diagnosis  of  delusion  at  once. 

Where  this  is  not  the  case  the  following  should  be  observed 
in  the  diagnosis : — 

An  idea  may  he  true  as  to  its  content,  hut  still  he  a  delusion. 
The  patient  reports  that  an  earthquake  occurred  to-day  in 
Italy.  The  journals  confirm  this  the  next  day.  In  spite  of 
this,  this  correct  assertion  originates  in  a  delusion,  for  if  asked 
whence  he  obtained  his  information,  the  patient  says  that  he 
observed  it  by  a  shaking  of  his  abdomen  or  that  his  "voice"  com- 
municated it. 

An  idea  may  he  false  as  to  content,  yet  not  he  a  delusion. 

Many  healthy  people  believe  in  a  corporeal  devil;  it  is  an 
error  which  has  been  taught  them.  The  demonomaniac,  who 
earlier,  perhaps,  did  not  have  this  belief,  knows  now  that  there 
is  a  devil  in  his  abdomen,  because  the  devil  speaks  in  his  brain. 

As  the  above  definition  of  delusion  states,  and  these  exam- 
ples explain,  the  conclusion  depends  upon  whether  an  idea  is 
a  delusion  or  not,  really  on  the  genesis  of  the  idea.     This  shows 


Delusions.  37 

in  the  delusion  that  a  momentary  sense  perception,  a  momentary 
idea,  a  momentarily  dominant  feeling  is  connected  with  another 
idea  with  which  it  should  not  be  connected  according  to  the  laws 
of  association ;  it  treats,  consequently,  of  a  disturbance  of  the 
coordination  of  ideas.  While  this  is  the  rule  for  the  first  ap- 
pearance of  a  delusion,  the  following  is  often  shown  in  its 
further  course:  An  image  of  memory  is  connected  with  impres- 
sions of  sense  perceptions  against  the  laws  of  association.  The 
earlier  idea,  with  which  the  momentary  perception  is  connected, 
is  generally  of  peculiar  emphasis. 

A  female  patient  sees  in  a  house  opposite  herself  a  man 
raise  a  roll  of  paper;  she  has  been  busily  occupied  with  her 
testament  before  this;  she  immediately  connects  perception  and 
the  reproduction  of  that  idea;  they  show  her  that  her  testament 
has  been  stolen. 

If  one  is  sucessful  in  ascertaining  the  first  appearance  of  a 
delusion,  it  is  often  possible  by  this  more  easily  to  explain  the 
further  ramifications  of  the  first.  The  path  of  abnormal  coordi- 
nation, once  trod,  become  passable,  finally  worn;  gradually 
other  ideas  are  led  by  the  same  way  also,  finally  all. 

Since,  of  the  ideas  which  become  associated,  one  at  least 
is  of  special  importance  for  the  Ego,  it  explains  the  retreat  of 
the  Ego  into  the  content  of  the  delusions,  ivhich  retreat  is  to  he 
regarded  as  a  characteristic  feature. 

If  now,  even  in  the  beginning  of  the  disease,  dou1)ts  offer 
exist  in  the  patient  in  regard  to  the  actual  basis  of  the  patholog- 
ical idea  pressing  upon  him,  the  patient  himself  will  often  ex- 
press such  doubts,  but  gradually  these  become  a  constituent  part 
of  the  spiritual  Ego,  and  by  this  incorrigible.  So-called  reason- 
able grounds,  the  bringing  in  of  objective  facts  which  prove  the 
real  incorrectness  of  the  ideas.  Judgments,  and  conclusions  of 
the  patient,  are  rejected  by  the  constancy  of  the  patient;  his 
views  are  defended  sometimes  with  skillful  braggadocio  or  by 
the  claim  of  supernatural  power. 

It  is  this  incorrigibility,  also,  which  sometimes  stamps  as 
delusions  ideas  whose  actual  basis  is  possible,  or,  at  least,  not 
contradicted. 

Here  it  is  not  the  quality,  but  the  quantity  of  the  idea  which 
makes  it  a  mania. 


38  General  Sj/mptomatology. 

Some  one  believes  that  lie  has  received  an  injury;  it  cannot 
be  proved  that  this  has  not  really  been  the  case;  that  idea  occu- 
pies the  individual  continually,  forces  all  others  back,  shove's 
itself  everywhere,  determines  the  patient's  words  and  actions. 
In  spite  of  all  disadvantages,  he  is  not  persuaded,  at  least  out- 
wardly, to  be  more  reserved.  The  mastery  of  the  idea  makes 
it  a  delusion. 

Many  querulant  manias  have  such  a  development. 

According  to  this,  there  are  to  be  designated  as  signs  of 
delusion : — 

1.  The  genesis  by  association  of  ideas  which  ought  not  to 
be  associated  by  the  law  of  association. 

2.  The  retreat  of  the  Ego  without  sufficient  reason. 

3.  Incorrigibility. 

The  diagnosis  must,  when  it  has  ascertained  the  presence 
of  delusions,  seek  further  to  find  out  to  which  primordial  system 
of  delusions  they  belong,  especially  whether  they  are  combined 
or  systematized  delusions. 

The  dissimulation  of  delusions  is  determined  by  the  same 
fundamental  principles  used  in  cases  of  hallucination. 

The  behavior  of  the  patient  when  he  believes  himself  un- 
observed by  physicians  and  attendants,  pieces  of  writing  which 
he  has  delivered  or  delivers,  suggestive,  opportune  questions, 
will  here  make  the  diagnosis  sure.  Sometimes  it  is  of  import- 
ance to  know  the  normal  instincts  and  habits  of  the  person 
investigated. 

'The  prognosis  and  treatment  of  delusions  depend  upon  the 
form  of  the  mental  disease  in  which  these  symptoms  appear. 
Efflorescent  megalomania  is  unfavorable  prognostically,  as  well 
as  systematized  delusions.  What  is  said  of  the  treatment  of 
hallucinations  applies  here;  the  attempt  to  reason  the  patient 
out  of  his  delusions  is  useless,  often  injurious,  since  the  patient 
becomes  excited  by  such  attempts  and  withdraws  his  confidence 
from  the  physician. 


■iocinlions.  39 


4.  Pathological  Weakness  in  the  Rapidity  and  Power 
of  the  Associations. 

So  far  as  this  is  based  on  a  defective  development  of  the 
oi'gan  of  the  mind,  it  will  be  discussed  under  idiotism. 

The  diininuiion  of  the  rapidity  of  the  associations  expresses 
itself  in  the  complaints  of  the  melancholiacs,  on  their  poverty 
of  thought,  in  the  slowness  with  which  questions  are  answered, 
actions  performed. 

It  is  found  in  melancholia,  hero,  perhaps,  from  an  in- 
stinctive fear  of  thinking,  because  every  spiritual  activity  causes 
pain  (perhaps  as  a  sufferer  with  a  neuralgic  affection  tries  to 
keep  the  affected  member  motionless),  in  the  most  diverse 
psychoses  Avith  states  of  mental  weakness,  in  terminal  dementia 
after  primary  functional  mental  disturbances,  in  states  of  intox- 
ication, especially  in  alcholism,  also  in  myxedema,  in  epilepsy, 
in  organic  dementia,  and  sometimes  is  especially  prominent  with 
brain  tumors  and  after  apoplectic  attacks. 

The  diminution  of  the  poiver  of  the  associations  is  shown : — 

(a)  In  the  lack  of  the  greater  or  less  emphasis  with  which 
these  are  completed  and  which  is  proper  to  them  in  normal 
conditions.  The  ideas  appear  equally,  and  even  equally  feebly, 
and,  under  these  conditions,  make  the  choice  more  difficult. 
From  this  arises  the  circumstantiality  of  narration  of  such  pa- 
tients who  do  not  know  how  to  separate  the  essential  from  the 
non-essential.  The  difficulty  of  the  formation  of  new  associa- 
tions is  shown  sometimes  in  the  repetition  of  one  and  the  same 
monotonous  word  as  an  answer  to  the  most  diverse  questions 
{perseveration) . 

(&)  In  the  partial  or  complete  loss  of  conceptions  ac- 
quired previously,  with  the  incapability  of  forming  new  ones. 

At  first  these  last  appear,  later  the  conceptions  last  ac- 
quired and  those  which  are  seldom  used  are  lost;  those  remain 
longest  which  are  regularly  used  in  the  worn  paths.  The  fact 
that  they  remain  is  due  to  the  power  of  reproduction  which  is 
still  present.  Here  belong  the  outer  conventionalities  with  offi- 
cers, the  technically  correct  prescription-writing  of  physicians, 
the  formality  of  judicial  procedure  with  jurists,  and  the  like, 
in  the  later  stages  of  mental  disease. 


40  General  Symptomatology. 

Even  the  sense  deceptions  previously  present  and  the 
delusions  gradually  fade  away,  are  finally  destroyed,  or  flicker 
up  only  occasionally. 

These  symptoms  of  diminished  or  finally  exhausted  mental 
activitv  form  the  essential  sign  of  so-called  weak-mindedness 
(the  lower  degree)   and  mental  imbecility   (the  higher  degree). 

The  last  ends  eventually  in  the  complete  destruction  of  the 
personality. 

Mental  weakness,  combined  with  a  certain  pathological 
consciousness,  often  leads  to  the  want  of  self-confidence,  of 
energy,  and  of  tlie  capability  of  decision,  to  the  so-called  want 
of  will-power  (abulia)  of  many  mental  invalids. 

Such  states  of  incomplete  or  even  of  complete  paralysis 
of  the  associations,  when  they  appear  transiently,  are  symptoms 
of  the  disturbance  of  consciousness  which  appears  in  the  twi- 
light and  stupor  states;  further,  they  appear  in  dementia  acuta 
and  with  apoplectiform  or  epileptiform  seizures  of  the  most 
various  organic  mental  diseases. 


III.  THE   DISTURBANCES   OF   REPRODUCTION. 
MEMORY. 

By  means  of  the  faculty  of  reproduction  we  are  in  position 
to  place  before  us  again  sense  perceptions,  ideas  with  the  judg- 
ments which  proceed  from  them,  conclusions,  even  the  total 
content  which  the  consciousness  had  in  a  given  moment.  We 
designate  this  capability  as  "the  faculty  of  memory.^' 

1.  Pathological  Heightening  of  the   Faculty  of 
Memory.     Hypermnesia. 

This  is  mostly  observed  in  mania  (consult)  and  generally 
consists  in  the  easy  calling  forth  of  the  images  of  memory  ac- 
cording to  the  acceleration  of  the  phenomena  of  association, 
and  also  in  the  increase  of  the  power  with  which  obscure  images 
of  an  earlier  time  may  be  brought  to  light. 

A  similar  condition  appears  in  hysteric  states  and  in  the 
first  stages  of  certain  intoxications  (alcohol,  morphine). 


Memory.  41 

2.  Falsification  of  the  Image  of  Memory.     Paramnesia. 

It  is  necessary  for  the  reproduced  image  to  correspond  with 
the  perception  originally  received  to  have  a  faithful  memory, 
and  that: — 

1.  This  perception  be  accompanied  in  its  genesis  by  a  eci-- 
tain  attention  and  a  certain  normal  tone  of  feeling,  and  b;' 
reproducible  by  this  means  (the  reproducibility  is  made  easier 
by  repetition  and  more  difficult  by  long  intervals). 

2.  If  we  treat  of  a  comparison  of  a  momentary  impression 
with  one  had  previously,  the  momentary  perception  occurs  nor- 
mally; and 

3.  That  a  normal  power  of  association,  which  is  necessary 
for  the  identification  of  the  first  idea,  is  present. 

If  any  of  these  conditions  are  wanting,  we  may  have 
falsification  of  the  image  of  memory;  this  is  formed  and  ex- 
pressed in  the  following  manner: — 

1.  The  image  to  be  reproduced  is  not  sufficiently  clear, 
because  the  above-mentioned  conditions  were  not  present  at  its 
reception. 

In  healthy  people  such  disturbances  of  the  memory  appear 
because  they  were  "distracted"  when  the  first  image  was  re- 
ceived, so  that  it  was  not  taken  clearly  enough.  In  those  de- 
mented, especially  in  paresis  and  senile  dementia,  it  shows 
itself,  e.g.,  in  the  following  manner:  The  physician  visits  the 
patient  to-day;  the  lack  of  poAver  of  attention  does  not  allow 
the  latter  to  fix  the  image  sufficiently,  and  the  next  day  the 
patient  sees  in  the  physician,  who  again  visits  him,  some  one 
whom  he  had  previously  known. 

According  to  the  dementia,  the  images  of  memory  of  the 
restored  patient  at  the  time  of  his  greatest  disease,  if  they  are 
present,  are,  also,  frequently  falsified,  only  exceptionally  en- 
tirely true,  by  which  the  disturbance  which  the  sense  percep- 
tion suffered  by  hallucinations  and  delusions  may  be  yet  ob- 
served. 

2.  The  image  momentarily  perceived  does  not  appear  in 
the  normal  way. 

In  defective  pow-er  of  attention,  in  the  rapid  change  of 
the  ideas  occupying  the  individual,  the  taking  up  of  the  image 


42  General  Symptomatology. 

is  transient,  and  unessential  constituents  of  it  sufl&ce,  e.g.,  for 
an  identification  in  the  memory  of  an  experienced  jjerson. 

3.  Tlie  association,  which  is  necessary  for  the  comparison 
of  a  momentary  perception  with  an  earlier  one,  is  disturbed 
pathologicalh',  or  it  \xi\\  associate  the  images  of  memory  of 
certain  facts  with  earlier  ones,  or  ideas  yet  present  which  do 
not  belong  to  the  first  in  fact  nor  in  time. 

The  commonest  of  the  falsifications  of  memory  which 
belong  here  are  tlioso  in  -which  the  momentarily  dominant  de- 
lusions mix  in  the  process  of  memory.  The  patient  believes 
that  he  recognizes  in  those  around  him  the  highest  dignitaries 
of  the  state,  by  signs  in  their  countenances  or  stature  corre- 
sponding with  his  great  ideas,  or  denies  the  identity  of  persons 
previously  known  to  him,  according  to  his  ideas  of  persecution. 
(See  delirium  ^lalingnosticum  and  metabolicum.) 

Many  patients  also  change  the  jDerceptions  and  occurrences 
preserved  in  their  memory,  according  to  their  system  of  mania 
{retroactive  construction  of  delusions,  Sommer). 

The  patient  remembers  that  even  in  his  youth  Ms  reputed 
father  showed  1)y  his  looks  and  gestures  that  he  was  not  his 
father.  "It  was  not  without  purpose  that  the  word  'cochon' 
(hog)  was  given  me  to  decline." 

(Especially  frequent  in  paranoiacs,  but  often,  also,  in  mel- 
ancholiacs.) 

That  play  of  disarranged  associations  is,  further,  to  be 
designated  as  falsifications  of  the  memorv,  in  which  momentary 
perceptions,  their  transformations  by  illusions,  dreams,  delu- 
sions, images  of  memory  from  books  and  journals  are  wildly 
confused,  and  incite  the  patient  to  the  narration  of  astonishing 
events  in  his  life,  to  the  most  noteworthy  hunting  stories,  or  to 
horrible  histories  of  robbers.  (Confabulations,  hallucinations 
of  the  memory.  Sully.) 

"With  the  contemporary  loss  of  the  capalnlity  of  attention 
and  the  total  lack  of  orientation  in  time  and  space,  this  kind  of 
paramnesia  forms  a  real  psychic  pathological  symptom  in  the 
disease  of  Korsakoff  (which  see). 

While  these  paramnesias  appear  mostly  only  in  states  of 
stiipor  or  of  considerable  mental  weakness,  a  discover^'  and 
reproduction  of  occurrences  which  have  not  taken  place  may 


Meinory.  43 

appear  on  a  pathological  basis  where  the  power  of  deliberation 
is  apparently  perfectly  retained.  Wishes  and  liopes,  romantic 
fancies,  likes  and  dislikes,  are  generally  melted  together  into 
occurrences  whose  report  shall  generally  serve  egoistic  pur- 
poses. (Pseudologia  phantastica,  pathological  liars  and  swin- 
dlers, Delbrlick.) 

Particularly,  when  the  patient  has  told  and  retold  his 
stories,  he  himself  does  not  doubt  their  actual  truth,  so 
much  the  less,  since  a  condition  of  mental  Aveakness  has  gen- 
erally made  a  critical  judgment  more  difficult. 

We  designate  as  an  identifying  form  of  the  deception  of 
the  memory  (Sander),  that  occurence  in  which  the  impression 
arises  that  one  has  already  seen  the  momentary  environment, 
that  one  has  already  seen  or  heard  once  before  in  the  same 
manner  what  one  sees  or  hears;  in  short,  that  one  has  already 
experienced  once  in  the  same  manner  the  situation  in  which 
he  finds  himself  for  the  moment. 

This  peculiar,  surprising  event  has  generally  something 
terrifying  in  it;  the  person  expects  something  unusual  will 
happen;  sometimes  illusions  conjure  up  new  images.  This 
mental  abnormality,  occasionally  appearing  in  the  healthy  espe- 
cially under  circumstances  of  bodily  or  mental  exhaustion, 
takes  place  oftener  with  epileptics  (here,  also,  intermitting 
and  periodically  in  connection  with  severe  attacks),  with  alco- 
holists,  sometimes,  also,  with  paranoiacs. 


3.  Pathological  Diminution  and  Destruction  of  the 
Power  of  Memory.     Amnesia. 

In  the  mildest  forms  the  weakness  of  the  faculty  of  mem- 
ory is  shown  in  the  greater  time  consumed  in  "consideration," 
that  is,  the  prolongation  of  the  average  time  in  which  an  image 
of  the  memory  can  be  called  into  the  consciousness. 

With  the  general  inhibition  of  mental  activity,  as  it  is 
'especially  show)i  in  melancholic  states,  that  disturbance  is 
common,  but  it  must  be  taken  into  consideration  that  the  time 
of  reproduction  of  the  image  of  memory  outwards  is  also  pro- 
longed. It  is  the  same  in  all  states  of  mental  weakness,  so  far 
as  there  may  not  be  a  loss  of  the  image  of  memory. 


44  General  Symptomatology. 


Amnesia  needs  only  to  meet  a  determined  series  of  images 
of  the  memory  localized  in  the  cortex. 

The  images  of  memory  of  the  acoustic  and  motor  speech 
centers  (sensory  and  motor  aphasia),  the  word-images  (alexia 
and  agraphia),  may  he  destroyed  separately. 

The  discussion  of  these  diseases  belongs  to  the  special 
pathology  of  brain  diseases. 

The  amnesia  may  be  partial^  in  so  far  as  only  single  data 
of  the  faculty  of  memory  are  preserved,  or  the  impression  of 
a  past  situation  can  be  retained  in  its  general  features,  but  not 
in  its  details   (summary  memory). 

This  kind  of  amnesia  sometimes  exists  in  epileptic,  alco- 
holic raving  states,  also  in  the  twilight  and  stupor  conditions, 
like  those  in  deliriimi  hallucinatorium. 

They  are  also  oftener  observed  with  wounds  of  the  head, 
where  the  patients  can  only  report  vaguely  the  accident  which 
befell  them. 

Senile  amnesia,  which  is  often  partial,  since  it  refers  only 
to  the  near  past,  rests  upon  the  loss  of  the  power  of  attention  at 
this  age.  Similar  symptoms  are  observed  in  paresis  and  in  other 
organic  mental  diseases. 

Amnesia,  in  very  different  degrees,  exists : — 

1.  For  that  which  arose  in  the  states  of  obscurity  or  efface- 
ment  of  the  consciousness  or  self-consciousness,  since  in  these 
states  a  reception  of  reproducible  images  does  not  take  place  at 
all,  or  only  in  a  limited  degree  (delirium  hallucinatorium, 
states  of  stupor  or  raving,  epileptic,  hystero-epileptic  seizures). 

2.  In  the  condition  of  effacement  of  the.  self -consciousness. 
Here  the  amnesia  ma}*  reach  a  degree  where  the  patient  does 
not  know  what  his  name  is  or  where  he  lives.  Here  belongs, 
also,  the  amnesia  of  the  conditions  of  double  or  alternating 
consciousness. 

3.  In  state?  of  mental  vcal-ness. 

Here  the  images  of  memory  which  are  oftenest  exercised 
generally  remain  longest;  the  patients  still  recognize  those 
nearest  connected  with  them,  but  have  forgotten  all  others;  the 
things  regularly  learned  in  early  youth  still  remain,  things 
acquired  later  have  vanished :  finally,  ever}i:hing  is  lost,  even 
the  memory  of  their  own  personality. 


Sensory  Feelings.  45 


The  names  of  rcLroacllvc,  or  retrograde  aiiinesia  liave  been 
given  to  that  loss  of  the  images  of  memory  which  refers  not 
only  to  the  beginning  and  the  time  of  the  pathological  condi- 
tion, but  which  extends  to  a  longer  or  shorter  period  of  time 
previous  to  the  disease. 

Sometimes  this  defect  concerns  an  exactly  limited  series 
of  daj's,  months,  or  even  years,  while  what  occurred  before 
this  period  may  be  very  well  reproduced.  With  exception  of 
this,  these  patients  show  no  anomaly  in  their  deliberations  and 
are  conscious  of  the  pathological  disturbance. 

Others,  on  the  contrary,  fill  up  the  time  where  this  defect 
of  memory  occurs,  with  all  sorts  of  events  which  never  took 
place,  they  confabulate  without  their  confabulation  reaching 
the  phantastic  heights  of  paramnesias;  it  appears  more  like 
an  excuse. 

It  is  possible  that  gradually,  especially  after  apoplectic 
attacks,  certain  images  of  memory  may  return;  oftener  they 
vanish  permanently.  In  addition  to  their  presence  after  apo- 
plectic attacks,  retrograde  amnesia  may  be  observed,  after  at- 
tempts at  hanging,  carbon  dioxide  intoxications,  after  injuries 
to  the  head,  after  epileptic,  eclamptic,  hysteric  seizures,  in 
which  they  sometimes  appear  periodically,  and  after  the 
paralytic  attacks  in  paresis. 


IV.  THE  DISTURBANCES  OF  THE  FEELINGS. 

1.  Disturbances  of  the  Sensory  Feelings. 

These  may  consist : — 

(a)   In  a  pathological  heightening; 

(h)   In  a  pathological  diminution;  and 

(c)  In  a  pathological  inversion,  that  is,  in  the  calling 
forth  of  feelings  of  pleasure  where,  under  normal  circum- 
stances, disg-ust  would  be  aroused. 

(a)   Pathological    Heightening   of   the    Sensory    Feelings. 

This  is  expressed  in  reference  to  the  feeling  of  hunger  as 
greediness,  as  it  shows  itself  in  idiocy,  in  the  various  secondary 


46  General  Symptomatology. 

states  of  mental  weakness,  in  katatonic  mental  disturbances; 
it  also  manifests  itself  with  especial  frequency  in  paresis. 

It  is  seldom  that  there  is  in  the  same  patient  contempo- 
raneously a  pathological  heightening  of  the  feeling  of  thirst, 
and  this  will  always  be  a  reason  to  examine  the  urine  repeat- 
edly  (diabetes  mellitus,  diabetes  insipidus). 

On  the  contrary,  an  inclination  to  the  immoderate  use  of 
alcoholic  drinks  is  very  often  shown  in  the  beginning  of  mania, 
further  in  the  beginning  of  paresis. 

Such  a  heightened  appetite  may  also  appear  periodically 
and  is  then  called  dipsomania  (Huf eland ).^ 

Periodical  alcoholism  arises  under  the  following  condi- 
tions : — 

1.  Inheritors,  especially  those  who  descend  from  alcohol- 
ists,  and  imbeciles  with  small  psychical  powers  of  resistance 
begin  to  drink  constantly  at  irregular  intervals,  especially 
when  they  assume  new  burdens  or  if  they  wish  to  forget  ob- 
stacles (pseudodipsomania,  Legrain). 

2.  Alcoholism  begins  with  an  attack  of  periodic  mania; 
the  drinking  is  conditioned  by  the  maniacal  state,  a  symptom 
of  which  is  that  the  alcoholic  jshenomena  partially  cover  the 
phenomena  of  the  mania, 

3.  This  may  cover  the  maniacal  phase  of  a  circular 
psychosis  in  which  the  depressive  phase  is  not  .very  prominent ; 
it  may  also  take  its  course  amid  reproaches  and  self-accusations 
on  account  of  the  excesses  committed. 

4.  The  periodic  drinking  may  be  brought  on  Ijy  a  periodic 
melancholia  or  hypochondria.  The  patient  has  tried,  in  an 
earlier  attack,  the  favorable  effect  of  alcohol  in  deadening  his 
physical  pain  or  his  bodily  infirmities,  and  he  uses  this  remedy 
at  the  beginning  of  a  new  attack.  In  a  similar  way  dipso- 
mania may  arise  with  periodically  appearing  neuroses. 

5.  On  the  basis  of  hysteria  a  heightened  appetite  for  alco- 
holic beverages  may  appear  periodically,  contemporaneous  with 
a  total  aversion  to  nourishment. 

6.  Dipsomania  may  be  of  epileptic  nature,  and  even  run 
periodically  like  an  epileptic  dream  state. 


^  Die    Dipsomanie.     Eine   ^Yissensellaftliche   Studie   von   R.   Gaupp. 
Jena,  1901. 


Sensory  Feelings.  47 


The  clinical  tyi^e  ^^'lliell  the  dipsomaniac  offers  is  chang- 
ing according  to  Ihe  cause  which  lies  at  the  hasis  of  the  ohses- 
sion  for  alcoholic  beverages,  and  is  also  effaced  by  the  symp- 
toms of  alcoholism.  It  appears  to  be  a  special  disease  as  little 
known  as  the  study  of  monomanias, 

(Esquirol  spoke  of  a  monomania  of  intoxication.) 

In  many  dipsomaniacs  there  is,  in  the  interval  between 
the  attacks,  a  complete  horror  of  alcoholic  beverages;  in  other 
cases  the  dipsomaniac  passes  into  chronic  alcoholism  after  tlie 
excesses,  often  to  the  extent  of  delirium  tremens. 

The  pathological  heightening  of  the  sexual  feelings  is 
shown  in  immoderate  cohabitation  (especially  in  the  beginning 
of  mania  and  paresis),  in  inveterate  onanists  (in  them  as 
in  the  various  kinds  of  the  psychoses  of  puberty;  also  in  hys- 
teric psychoses,  especially  at  the  climacteric,  sometimes  after 
apoplectic  attacks,  and  oftener  at  the  beginning  of  senile  de- 
mentia) . 

In  men  it  leads  to  satyriasis^  in  women  to  nymphomania, 
in  both  to  narcism  (observation  of  their  own  naked  bodies 
with  voluptuous  ideas). 

Sometimes  men  use  for  the  heightening  of  their  pleasure, 
especially  for  the  carrying  out  of  onanism,  peculiar  objects 
which  women  have  used :  pocket-handkerchiefs,  aprons,  locks 
of  hair  (fetichism,  from  fetisso,  Portuguese,  enchantment). 

Onanism  in  early  childhood  (at  the  age  of  from  3  to  3 
years)  and  the  sexual  excitement  described  as  paradoxia  sex- 
ualis,  in  children  from  8  to  10  years  (generally  connected  with 
imbecility,  inclination  to  immoral  actions)  are  to  be  men- 
tioned as  an  abnormality  of  the  sexual  feelings.  A  heighten- 
ing of  the  sexual  feelings  is  sometimes  shown  contempora- 
neously with  feelings  of  anxiety  in  severe  hypochondria  and 
hypochondric  melancholia.  The  impulse  to  onanism  here 
overcomes  all  good  intentions;  the  onanism  itself  becomes  the 
source  of  new  culpability.  In  many  cases  onanism — ^without 
the  heightening  of  sensory  feelings — is  used  as  a  remedy  or 
alleviation  for  the  constant  torments  of  hypochondriacs  or 
hypochondric  paranoiacs. 


48  General  Symptomatology. 

(b)  The    Pathological     Diminution    or    Destruction     of    the 

Sensory   Feelings 

is  exemplified  in  reterence  to  the  feeling  of  hunger  as  anorexia, 
even  to  the  refusal  of  food  (sitophobia,  which  see)  ;  even 
the  thought  of  eating  arouses  disgust;  in  regard  to  the  feeling 
of  thirst,  as  hydrophobia,  which  without  reference  to  lyssa 
humana,  may  appear  in  dipsomaniacs  after  the  termination  of 
the  attack^  in  physchoses,  in  hypochondric  phychoses  with  the 
fear  of  having  been  bitten  by  a  mad  dog,  and  in  hysteric 
psychoses. 

With  the  frequent  and  forcible  contraction  of  the  muscles, 
that  sensation  which  we  call  muscular  feeling  becomes  con- 
densed to  a  feeling  of  fatigue.  This  feeling  of  fatigue  may 
even  be  wanting  in  pathological  states. 

The  absence  of  the  feelings  of  hunger  and  thirst  is  a  com« 
mon  phenomenon  in  the  maniacal. 

Diminution  or  entire  want  of  sexual  feelings  is  observed 
in  inheritors,  in  idiotism,  chronic  alcoholism,  organic  psychoses 
(with  tabetic  symptoms),  and  in  the  advanced  cases  of  de- 
mentia. 

(c)  The  Pathological  -Inversion  in  the  Feelings  of  Pleasure 
Where  Disgust  Would  Arise  Under  Normal  Conditions. 

The  transition  from  the  physiological  to  the  pathological 
evokes  that  desire  in  pregnant  and  hysteric  persons  for  unnatural 
articles  of  food,  which  is  designated  by  the  name  "pica." 

In  mental  disease  (in  the  state  of  raving,  in  dementia  of 
high  degree,  in  epileptics)  aj^pear  the  devourers  of  feces  and 
drinkers  of  urine,  designated  as  "coprophagi,"  in  whom,  con- 
temporaneously perhaps,  there  is  an  anesthesia  of  the  affected 
sensory  centers.  "Anthropophagi"  are  also  observed  (alcoholists 
and  epileptics). 

The  perversities  of  the  sexual  feelings,  which  lead  to  crim- 
inal acts,  have  been  extensively  elaborated  on  account  of  their 
legal  significance. 

These  may  appear  under  the  following  forms : 

1.  ^45  contrary  sexual  sensation  with  or  without  satisfac- 


Sensory  Feelings.  49 


tion  of  sexual  desire  in  the  same  sex :  pederasty  in  men  and 
Lesbian  love  in  women   (tribadism). 

It  appears  in  tliose  mentally  normal,  in  libertines,  often 
in  those  heavily  tainted  hereditarily,  in  the  beginning  of  psy- 
choses, also,  especially,  in  the  beginning  of  paresis  and  in 
alcoholists.  In  sporadic  cases  pederasty  is  practiced  because 
the  passive  pederast  wishes  to  enjoy  the  sensation  of  the  active. 

2.  As  exlilhitionism,  exposing  the  membrum  virile  in  the 
street  with  or  without  onanistic  motions.  (In  women,  exposure 
of  the  breasts).     This  may  have  various  causes  and  arises 

(a)  To  bring  on  a  voluptuous  feeling  by  it,  to  show  the 
naked  organ  to  women  that  they,  as  the  exhibitionist  assumes, 
may  experience  sensual   excitement. 

The  strength  of  the  first  attempt  at  exhibitionism,  as  in 
other  recurring  abnormal  actions,  may  be  understood  from  the 
following  forensic  case:  A  teacher  of  the  best  reputation,  when 
he  was  fifteen  years  old,  was  surprised  by  a  servant  girl  while  he 
was  masturbating.  She  was  very  much  amused  over  it.  Since 
then  he  had  pleasure  in  onanism  only  when  a  woman  saw  him, 
and  he  thought  that  she  would  be  excited  sensually  by  the  spec- 
tacle. AVith  this  object  he  would  expose  his  penis  in  the  streets 
and.  wait  till  a  woman  approached. 

(6)  As  the  expression  of  hypochondric  sensations  of  anx- 
iety localized  in  the  external  genitals,  which  are  only  alleviated 
by  exposing  the  sexual  organs  without  reference  to  the  conse- 
quences. 

(c)  In  epileptoid  seizures  (relatively  frequent),  in  which 
this  action  is  incessantly  repeated. 

(fZ)  In  the  beginning  of  paresis  and  senile  dementia,  in 
alcoholists  and  epileptics;  with  the  loss  of  the  intellectual  feel- 
ings for  decency  and  custom,  culpability  and  shame. 

(e)  In  imbeciles  who  have  not  attained  the  development 
of  these  feelings. 

3.  ^s  sexual  feelings  for  cMldren.  "With  libertines,  in- 
heritors, imbeciles  and  idiots,  with  the  last  sometimes  because 
mature  women  refuse  them,"  but  especially  with  epileptics,  alco- 
holists, apoplectics,  and  in  senile  dementia. 

4.  As  Jieightening  sexual  feelings  hy  'wounding  one's   vic- 

4 


50  General  Symptomatology. 

tim,  a  woman  or  a  boy  (sadism,  Toluptuous  murder  in  the  high- 
est degree),  or  by  injuring  one's  own  person  (masochism). 

5.  As  a  desire  for  sexual  satisfaction  with  animals  (sod- 
omy), witli  corpses  (necrophilism),  especially  prevalent  in  epi- 
leptic-s,  alcoholists,  and  imbeciles, 

6.  Finally,  here* belong  the  feelings  of  sexual  love  and 
the  carrying  out  of  cohabitation  with  relatives  of  the  ascending 
and  descending  line  (incest),  in  imbeciles,  sometimes  on  the 
basis  of  paranoic  delusions. 

A  man  made  pregnant  Ms  imbecile  daughter  of  eighteen 
years  in  order  to  beget  the  second  Saviour  with  the  Virgin,  for 
which  he  believed  that  he  had  been  called  through  divine 
mission- 

We  comprehend  the  sum  of  the  sensory  feelings  under  the 
name  of  ordinary  feeling. 

This  is  in  a  state  of  normal  equilibrium  when  the  feelings 
are  normal;  it  becomes  a  pathological  feeling  when  any  patho- 
logical phenomenon  in  the  organs  of  the  body  gives  a  painful 
stimulus  to  the  consciousness. 

In  the  mentally  diseased  a  pathological  feeling  may  be 
present  with  special  reference  to  an  existing  brain  disease.  So, 
e.g.,  in  imbeciles,  sometimes  in  intoxication  psychoses,  oftener 
in  the  beginning  of  the  psychosis.  The  feeling  of  a  determined 
change  may  rise  to  the  perception  of  disease,  thus  in  the  be- 
giuning  of  the  attacks  in  periodic  or  circular  psychosis;  quite 
often,  also,  in  the  beginning  of  paresis,  with  correct  diagnosis 
on  the  part  of  the  patient. 

GJenerally,  however,  the  feeling  of  disease  is  abnormally 
heightened  or  abnormally  depressed,  or  entirely  deficient. 

We  find  the  abnormal  heightening  in  psychoses  with  h}-]DO- 
chondric  delusions,  especially  in  hypochondrie  melancholia 
and  paranoia. 

The  feeling  of  disease  is  depressed  or  is  absent  :n  moral 
melancholia.  'T.  am  perfectly  well,  but  badly ;"  in  mania,  as  in 
the  maniacal  stages  of  other  psychoses,  even  the  feelings  of  dis- 
ease which  correspond  to  actual  disease  (diseases  of  the  heart, 
lungs)  vanish. 

Intercurrently,  the  feeling  of  disease,  and  even  the  per- 


Feelings  of  Judgment.  51 

ception  of  disease,   appear   in  mania  and   delirium   hallucina- 
torium. 

2.  Disturbances  of  the  Feelings  of  Judgment, 
(a)   Their    Pathological    Heightening. 

The  heightening  of  single  feelings  of  the  judgment  is  quite 
frequent  in  those  mentally  diseased,  especially  of  the  religious 
feelings  with  piety  and  impiety  in  contrast. 

An  immoderate  pathological  tendency  to  piet}',  to  a  "^'new 
awakening,"  to  a  participation  in  new  religious  sects,  appears 
in  imbeciles,  hysterics,  epileptics;  an  exaggeration  of  the  feeling 
of  atonement  appears  in  melancholiacs,  also  in  the  melancholic 
stages  of  the  various  psychoses. 

(b)   Pathological   Diminution. 

Indifference  to  what  is  good  or  bad,  want  of  altruistic  feel- 
ings, even  exaltation  of  the  egotists,  lack  of  interest  for  the 
high  and  the  low,  decency  and  indecency  are  present  in  a  greater 
or  less  degree  in  all  states  of  mental  weakness. 

In  idiotism  these  feelings  do  not  generally  reach  develop- 
ment; in  functional  psychoses  their  permanent  loss,  with  the  di- 
minution of  the  other  morbid  symptoms,  points  to  a  transition 
to  secondary  dementia.  Sometimes  the  retrogradation  of  the 
intellectual  feelings  forms  the  first  sign  of  an  organic  psychosis, 
so  in  paresis  and  dementia  senilis.  The  patients  are  immodest 
in  word  and  deed,  are  careless  about  their  toilet,  enter  draw- 
ing-rooms without  removing  their  hats,  or  bring  public  women 
into  their  families. 

In  the  early  stage  of  chronic  alcoholism  indifference  to  the 
fate  of  one's  family,  scanty  respect  and  disgust  for  former 
friends,  the  upbraiding  of  near  relatives,  finally  conflicts  with 
the  pohce,  punishments,  imprisonments  are  wont  to  announce 
the  diminution  or  loss  of  those  feelings. 

While  some  of  the  epileptic  psychoses  Likewise  prove  the 
loss  of  the  feelings  of  judgment  in  the  manner  just  described, 
the  want  of  ethical  feelings  is  present  in  the  hysteric  psychoses 
of  girls  and  women,  in  having  love  affairs  with  inferiors  and 
menials,  in  undressing  before  the  physician.     In  the  beginning 


52  General  Symptomatology. 

of  their  disease  maniacs  have  very  often  a  careless  and  indecent 
behavior,  commit  immoral  offences,  steal,  lie  and  cheat. 

Sometimes  during  the  convalescence  there  remains  a 
diminution  of  the  intellectual  feelings  for  some  time,  while  the 
other  symptoms  of  mental  disease  have  vanished. 

(c)  Pathological   Inversion  of  the   Feelings  of  Judgment. 

Perversity  consists  in  the  patient's  finding  peculiar  enjoy- 
ment in  those  actions  which  cause  others  pain  and  mortification. 

Such  patients  have  had  in  their  early  youth  a  special  joy 
in  torturing  animals,  in  killing  them  in  a  savage  manner,  in 
destroying  and  befouling  the  school-books  of  their  pla3'mates; 
they  steal,  set  things  on  fire,  and  do  not  enjoy  the  deeds  them- 
selves as  much  as  the  thought  of  the  trouble  and  pain  they  have 
broiight  on  their  victims. 

They  find,  also,  peculiar  pleasure  in  deceiving  others  by 
lying  and  cheating. 

The  feeling  of  shame  is  wanting  when  the  untruth  is  shown 
to  the  liar,  and  this  deficiency  favors  the  repetition  of  the  of- 
fence. 

In  later  life  these  individuals  commit  various  crimes. 

TVe  have  designated  the  defective  development  or  loss  of 
the  feelings  of  judgment  and  the  transformation  of  decency 
into  indecency,  a  circumstance  which  often  expresses  itself  in 
crime,  or  at  least  in  criminal  tendencies,  as  a  special  mental 
disease  which  may  subsist  by  itself  without  the  presence  of  other 
disturbances  of  the  mental  activity,  and  which  is  called  moral 
insanity  (Prichard).^ 

(As  early  as  1819  Grohmann.  spoke  of  immediate  moral 
disorganization  of  the  free  will,  of  moral  obtuseness,  the  bru- 
tality of  the  will,  and  moral  imbecility.) 

In  opposition  to  this,  however,  I  must  hold  that  a  man 
who  shows  these  abnormalities  exclusively  and  alone  is  a  crim- 
inal, and  that  we  only  have  a  patient  when  other  symptoms  of 
mental  disease  can  be  shown. 


^  ]Mondel  in  Eulenbiirg's  Realencyclopedia,  Xiicke,  Xeurologisches 
Centralblatt.  1S96.  Binswanger.  Volkmann's  Sammlung,  1887.  Cramer, 
Miinclmer  ^Medicinische  \Yochenschrift,  1898,  Xo.  4G. 


Feelings  of  Judgment.  53 


The  group  of  symptoms  of  so-called  moral  insanity  ap- 
pears : — 

1.  Preferably  in  imbeciles,  in  whom  the  question  is  not 
of  the  loss  or  inversion  of  the  feelings  of  judgment,  but  of  their 
defective  development,  which  is  connected  ivith  the  symptoms 
of  intellectual  weahiess.  It  has  to  do  with  individuals  who 
are  almost  always  heavily  tainted  by  heredity,  who  are  distin- 
guished, even  before  the  time  of  going  to  school,  by  their  bru- 
tality to  animals,  by  their  quarrels  with  their  brothers  and 
sisters,  by  their  disobedience  to  their  parents.  They  are  inat- 
tentive and  lazy  in  school,  disturb  the  lessons  by  disorderly  be- 
havior, take  away  the  belongings  of  their  schoolmates,  destroy 
their  tablets  and  books,  and  lie.  By  dint  of  compulsion  and 
trouble  they  pass  through  a  few  classes  or  wander  from  one 
school  to  another,  from  one  boarding-house  to  another.  Every- 
where they  get  into  trouble  by  their  depravity,  by  their 
criminal  tendencies,  to  which  are  added,  often  long  before 
puberty,  onanism,  more  often  crimes  against  morality  (para- 
doxia  sexualis).  This  is  repeated  when  they  are  dismissed 
from  school  and  take  up  some  calling.  By  a  vagabond  life, 
stealing,  incendiarism,  they  come  into  conflict  with  the  police 
and  the  criminal  law,  and  are,  unless  an  expert  examination 
is  made  of  their  mental  condition,  sentenced  to  prison,  but 
continue  their  former  life  after  the  expiration  of  the  punish- 
ment. A  good  proportion  of  the  habitual  criminals  is  com- 
posed of  such  imbeciles. 

Headaches,  dizziness,  epileptoid,  and  epileptic  seizures  very 
frequently  accompany  them  from  their  youth  up. 

Generally  a  large  number  of  the  stigmata  of  degeneration, 
especially  malformation  of  the  cranium,  deformities  of  the 
ears,  harelip,  malformation  of  the  palate,  deformities  of  the 
sexual  organs,  and  others,  are  found. 

2.  In  alcoholists,  with  other  symptoms  of  chronic  alcoholic 
intoxication,  and  in  morphinism. 

3.  In  epileptics,  with  the  symptoms  of  epileptic  psychosis. 

4.  In  the  beginning  of  paresis,  likewise  in  senile  dementia, 
connected  in  both  cases  with  symptoms  of  mental  weakness. 

5.  In  hysteric  psychoses,  especially  frequent  with  sexual 
anomalies. 


54  General  Si/mptomatology. 

G.  In  the  beginning  of  mania,  but  especially  in  the  ma- 
niacal stage  of  circular  insanity,  and  very  frequently  in  the 
attacks  of  periodic  mania. 

7.  In  paranoia.  Here  the  immoral  actions  appear  against 
all  possible  persons,  often  against  those  otherwise  indifferent, 
as  revenge  on  "the  whole  world"  for  all  the  chagrin  which  the 
patient  asserts  that  he  has  suffered  from  his  childhood ;  really 
in  a  greater  or  less  degree  for  what  he  has  suffered  during  his 
misconception  of  his  pathological  condition. 

According  to  this,  if  there  is  not  a  mental  disease  which 
should  be  designated  as  "moral  insanity,"  there  is  still  less 
such  a  one  which  would  consist  solely  in  the  inversion  of  a 
determined  intellectual  feeling  after  the  analogy  of  a  "fixed 
idea.^' 

Kleptomania,  pyromania,  tlie  mania  for  murder  are  either 
no  monomanias,  since  the  criminal  tendencies  appear  as  par- 
tial s^-mptoms  of  a  psychosis  which  may  be  of  very  different 
forms,  or  the  so-called  monomaniacs  are  to  be  designated  as 
criminals. 

The  "aidoiomonomaniacs"  have  already  been  mentioned 
in  the  treating  of  perversions  of  the  sexual  feelings. 


V.  THE  DISTURBANCES  IN  THE  CONDITION 
OF  THE  MIND. 

The  aggregate  of  the  feelings  which  accompany  the  con- 
tent of  consciousness  we  designate  as  '"mind."  The  lack  of  the 
development  of  its  components,  as  Avell  as  each  essential  change 
in  them  from  pathological  causes,  will  bring  forth  a  patholog- 
ical disturbance  of  the  mind. 

The  influence  of  the  sensory  feelings  on  the  mind  is  shown, 
e.g.,  by  the  pathological  ca?nesthetic  sensations,  as  of  the  stom- 
ach and  intestines  and  the  depression  of  the  mind  connected 
with  them. 

Bet^reen  the  jDessimist,  ruled  by  feelings  of  dissatisfac- 
tion, of  whom  the  "grumbler"  is  only  an  inferior  kind,  and  the 
joyful  optimist,  there  are  as  many  varieties  in  disposition  as 
between  the  melancholiac  filled  with  anxiety,  in  a  panphobic 


Condition  of  the  Mind.  55 

(lelirimn,  and  the  paretic  swimming  in  a  sea  of  iiappinesss. 
HypoiiK'lancliolic  depression  on  one  side,  hypomaniaca]  and 
maniacal  license  form  intermediate  degrees. 

The  complete  loss  of  all  feelings  of  pleasure  or  displeasure, 
oftener  with  a  certain  remainder  of  sense  feelings,  is  designated 
obiuseness  of  the  mind,  and  conditions  apathetic  mental  im- 
becility with  loss  of  intelligence,  while  it  is  observed  (mly  with 
the  weakening  of  the  intelligence,  especially  in  alcoholists  and 
epileptics. 

The  momentary  condition  of  the  mind  is  called  frame  of 
the  mind,  or  disposition. 

So  far  as  peculiarly  prominent  feelings  are  present,  the 
frame  of  mind  is  only  the  expression  of  those  feelings. 

Attention  is  directed  here  only  to  the  easy  changeahility 
of  the  frame  of  the  mind  in  the  mentally  diseased,  the  quick 
and  apparently  wholly  unmotived  or  insufficiently  motived 
change  of  the  mind  (emotivity).  "Shouting  to  Heaven,  sor- 
rowful as  death,"  "laughter  and  weeping  in  one  breath." 

This  appears  as  a  prominent  symptom  of  inheritors,  is 
especially  frequent  in  hysteric  psychoses,  often  present  with 
epileptics  also,  those  who  curse  and  pray  alternately.  Very  often 
a  certain  emotivity  remains  as  the  remnant  of  mental  diseases 
which  have  been  cured. 

The  sudden  change  in  the  frame  of  the  mind  is  shown  in 
the  affections,  as  anger  and  rage,  as  anxiety  from  the  feelings 
of  displeasure,  as  boisterousness,  immoderate  Joy  from  the 
feelings  of  pleasure. 

The  expression  of  such  affections,  that  is,  their  external 
signs,  are  the  freer  in  those  mentally  diseased,  as  the  inhibiting 
ideas  are  limited  in  power  or  pushed  away;  the  affection  be- 
comes pathological.  Such  pathological  affections  are  observed 
in  imbeciles,  epileptics,  alcoholists,  especially  in  inheritors, 
for  the  condition  of  the  consciousness  with  these,  see  VI.  The 
Disturbances  of  the  Consciousness. 

Of  these  emotions  anxiety  has  a  special  interest,  and  its 
appearance  as  a  cardinal  symptom  has  caused  some  authors  to 
speak  of  a  peculiar  form  of  psychosis,  psychosis  of  anxiety 
(Wernicke). 

Anxiety  may  l)e  brought  on  by  tlie  new  interpretntion  of 


56  General  Si/mptomatology. 


indifferent  sense  imjDressions  in  the  individual  so  threatened, 
by  fearful  hallucinations,  by  tormenting  ideas,  and  by  abnormal 
sense  feelings  (fear  of  death,  etc.)  ;  once  called  forth,  they 
transform  other  perceptions,  ideas,  and  feelings  to  conformity 
with  themselves,  and  may  reach,  by  an  ever  self-renewing  patho- 
logical stimulus,  a  condition  of  anxiety,  lasting  for  weeks  and 
months,  which  may  be  connected  with  certain  feelings  of  local- 
ized anxiety  in  the  thoracic  cavity  (precordial  anxiety),  in  the 
head,  in  the  forehead,  in  the  neck,  or  in  the  sexual  organs. 

Irradiation  to  the  central  motor  apparatus  leads  in  many 
cases  to  violent  deeds  (anxious  raving,  e.g.  in  melancholia, 
raptus  melancholicus),  or  to  complete  motor  inhibition  (the 
patient  is  stiff  with  anxiety,  "as  if  thunderstruck") . 

The  diminution  of  anxiety  may  either  signify  the  diminu- 
tion of  the  svmptoms  calling  it  forth  and  the  Ijeginning  of 
recovery  from  the  disease,  or  signalize  the  entrance  of  a  general 
weakness  of  the  psychic  functions  which  marks  the  transition 
of  a  curable  psychosis  into  one  incurable. 

The  diminution  of  the  affection,  with  the  other  patholog- 
ical symptoms  unchanged,  is  generally  to  be  regarded  as  an 
unfavorable  symptom  of  prognosis. 

Besides,  in  melancholia,  in  which  the  emotion  of  anxiety 
is  a  common  phenomenon,  it  is  observed  in  the  depressive 
(melancholic  and  h3'pochondric)  condition,  types  of  the 
various  psychoses  (paresis,  senile  dementia,  delirium  hallucina- 
torium),  it  is  developed  in  a  characteristic  manner  from  the 
hallucinations  of  alcoholists  and  quite  often  out  of  the  hallu- 
cinations in  epileptics. 

So  far  we  have  spoken  of  general  states  of  anxiety  with 
undetermined  or  changing  content,  yet  there  is  still  an  anxiety- 
emotion  "which  is  connected  with  the  feelings  of  displeasure 
and  even  in  the  province  of  the  ordinary  feelings. 

These  emotions  of  anxiety  are  known  under  the  name  of 
liliohias  and  are  connected  essentially  with  the  fear  of  disease. 

Eelief  from  this  anxiety  conditions  either  certain  external 
relations  or  certain  abnovmal  sensations  in  one's  own  body.  To 
the  first  belongs  agoraphobia  (fear  of  a  vacant  place),  mono- 
phobia, hypsophobia  (anxiety  at  great  heights),  nyktophobia 
(anxiety  before  and  during  the  night),  claustrophobia    (fear 


Condition  of  the  Mind. 


of  remaining  in  a  closed  room).  The  patient  fears  to  go  over 
a  great  vacant  place,  because  he  once  had  an  attack  of  dizziness 
in  going  over  such  a  place,  or  was  only  afraid  of  an  attack  of  diz- 
ziness, and  had  great  anxiety  from  it  because  no  house  was  near. 
He  is  afraid  of  the  anxiety  which  he  might  experience  again. 
He  is  afraid  of  being  alone,  because  something  might  pass  him, 
and  then  he  would  be  without  aid.  He  does  not  go  over  a 
bridge,  does  not  stand  by  an  o})cn  window,  because  he  is  afraid 
of  becoming  suddenly  dizzy,  or  of  being  enveloped  in  darkness 
and  in  this  condition  might  jump  down. 

The  idea  of  a  suddenly-appearing  mental  disease  also 
forms  the  foimdation  for  the  "knife  anxiety"  and  similar 
states,  in  which  the  patient  is  apprehensive  at  the  sight  of  a  knife, 
fearing  that  he  may  become  so  violently  affected  by  mental  dis- 
ease as  to  kill  himself  or  another  with  a  knife. 

In  all  such,  cases  it  is  essential  to  determine  what  the 
psychic  occurrence  was  when  the  anxiety  first  appeared.  If 
this  is  not  done,  the  logical  connection  between  the  object  caus- 
ing the  anxiety  and  the  subjective  condition  is  often  not  recog- 
nized. In  repetitions,  especially  in  frequent  repetitions  in 
which  the  occurrence  is  completed  through  worn  paths,  the 
original  basis  no  longer  comes  to  the  consciousness;  an  un- 
motived  compulsion  seems  to  be  present  by  which  these  phobias 
have  received  falsely  the  name  of  imperative  concepts,  while 
they  are  actually  anxiety  ideas,  and,  as  shown,  are  mostly  of  a 
hypochondric  nature. 

In  this  class  of  phobias,  belong,  also,  the  cases  in  which 
the  patient  is  everywhere  afraid  of  the  germs  of  disease,  of 
poisons,  of  sharp  objects  whose  touch  even  will  cause  wounds  or 
disease  (bacillus  fear,  arsenic,  morphine  fear,  fear  of  splinters, 
of  needles,  of  dirt  [mysopJiohia]). 

These  states  have  been  designated  the  mania  of  doubt  u'itJi 
fear  of  touch  (folic  du  doute  avec  delire  du  toucher). 

As  a  consequence  of  the  fear  of  being  or  having  been  in- 
jured by  poison  or  dirt,  in  many  cases  the  impulse  to  washing 
appears,  to  which  the  patient  yields  without  resistance  (wash- 
ing mania). 

This  mania  of  doubt  with  fear  of  touch  appears  far  oftener 
in  women  than  in  men,  especially  between  the  ages  of  35  to  35 


58  General  Symptomatology. 

years  and  iipwards;  it  is  sometimes  shown  as  the  heightening  of 
a  hypochondria  in  those  heavily  tainted,  and  appears  first  with 
the  breaking  out  of  epidemics. 

This  condition  rims-  its  course  with  exacerbations  and 
remissions,  seldom  makes  a  complete  recovery,  but  in  institu- 
tions leads  only  occasionally  to  mental  weakness.  G-enerally, 
the  circle  in  which  the  patient  moves  and  in  which  his  inter- 
ests are  concentrated  becomes  even  more  contracted  if  the  con- 
dition is  not  improved  by  suitable  treatment.  It  may  even 
lead  to  a  complete  loss  of  intercourse  with  men. 

The  treatment  is  essentially  a  psychic  one,  with  the 
methodic  use  of  cold  water,  bromide,  arsenic,  and  quinine.  The 
institution  treatment,  eventually  a  sanitarium,  cannot  be 
avoided  if  the  patient's  presence  in  the  family  is  unbearable, 
and  especially  if  it  becomes  injurious  to  the  children. 

This  sort  of  mania  of  doubt  with  fear  of  touch  is  to  be 
distinguished  from  that  which  arises  from  another  wholly  dif- 
ferent psychic  process,  a  determined  disturbance  in  the  asso- 
ciations (cf.,  paranoia  rudimentaria). 

Further,  anxiety  may  be  resolved  into  certain  abnormal 
sensibilities  of  the  body  (paresthesias  and  hyperesthesias). 
These  sensibilities  ha^-e  very  frequently  their  seat  in  the  sexual 
organs    (onanism,  exhibitionism  with  anxiety). 

A  patient  was  in  continual  fear  lest  he  should  crush  his 
penis  in  sitting,  lest  the  hair  on  that  part  of  the  body  should 
be  torn,  lest  he  might  have  headache  from  it. 

In  hystericals  the  anxiety  is  localized  in  the  abdomen  or 
bladder  (torturing  anxietj^  for  fear  of  emitting  flatulence,  of 
urinating  in  company),  while  in  others  it  may  be  localized  in 
the  teeth  {dental  obsession). 

The  states  of  anxiety  described  may  accompany  the  most 
varied  psychoses,  especially  those  with  delusions,  but  they  may 
be  present  without  the  individual  being  suspected  of  having  any 
mental  disease. 

In  the  last  case,  however,  the  sudden  heightening  of  the 
anxiety  may  bring  forth  some  disturbance  in  the  continuity 
of  the  ideas:  a  disturbance  of  discretion  may  appear  which  will 
lead  to  abnormal  actions  {emotional  actions). 


Disturbances  of  Consciousness.  59 

VI.  THE  DISTURBANCES  OF   CONSCIOUSNESS. 

The  content  of  consciousness  in  the  mentally  normal  in- 
dividual will  be  very  different  according-  to  his  mental  endow- 
ment and  education,  his  calling  and  position.  It  may  be  lin'- 
ited  in  those  mentally  diseased  (idiotism,  acquired  dementia), 
or  it  may  be  distorted  by  hallucinations  and  delusions ;  both  kinds 
of  disturbances  are  very  often  connected  in  the  same  indi- 
vidual. 

The  accompanying  disturbances  have  already  been  dis- 
cussed. Here  mention  will  only  be  made  of  the  general  con- 
tent of  consciousness  as  it  appears  externally.  The  equilib- 
rium in  perceptions,  ideas,  and  feelings  is  shown  exteriorly  as 
circumspection.  With  this  is  also  connected  the  capability  of 
orienting  one's  self  in  regard  to  time  and  space. 

The  insane  are  often  distinguished  by  the  want  of  circum- 
spection, sometimes  because  they  are  not  oriented  in  regard 
to  the  place  where  they  are,  or  the  vicinity,  or  the  time  (dis- 
orientation). Apparent  constant  circumspection,  however,  does 
not  exclude  the  presence  of  a  mental  disease.  The  want  of  in- 
telligence may  be  concealed  by  the  observance  of  outer  forms. 
Sense  deceptions  and  delusions  may  be  suppressed  or  their  ex- 
ternal manifestation  be  kept  in  abeyance  temporarily  (espe- 
cially in  paranoia,  also  in  alcoholism).  Sometimes  the  appear- 
ance of  circumspection  in  the  insane  is  intermittent,  transitory, 
especially  in  mania,  delirium  hallucinatorium,  oftener  in  in- 
toxication phycoses,  less  often  in  paresis.  The  patient  declares 
suddenly  that  he  knows  now  where  he  is,  that  he  has  said  some- 
thing very  foolish,  that  he  must  have  been  sick. 

The  opposite  of  circumspection  is  confusion,  a  patholog- 
ical condition  of  the  consciousness  in  which  the  internal  con- 
nection of  the  ideas  becomes  lax,  the  connection  does  not  obey 
the  normal  laws  of  association.  In  it  the  conception  of  time 
and  space  is  wanting.  This  state  is  expressed  externally  by 
confused  speeches  and  aimless,  disconcerted  actions. 

Confusion  may  arise: — 

1.  By  numerous  hallucinations — liallucinaiory  confusion 
— which  enter  with  clouding  of  the  consciousness  and 
may  appear  as  a  symptom  of  the  most  varied  psychoses. 


GO  General  Symptomatology. 

Here  belong  the  confusion  of  feverish  patients  and  that 
of  the  intoxication  ps3'clioseS;,  many  cases  of  epileptic  confusion, 
as  in  delirium  hallueinatorium  and  transitorily  in  paranoia. 

2.  By  everting  the  ideas,  as  in  maniacal  confusion,  which 
is  observed  in  the  various  types  of  maniacal  excitement,  but 
especially  in  raving  mania  (see  this). 

3.  By  the  intrusion  of  too  exuberant  emotions  into  the  con- 
sciousness. Even  in  those  mentally  normal,  a  very  great  joy, 
but  especially  an  unmeasured  anxiety,  may  lead  to  incoherent 
speeches.  Transitorily  anxious  confusion  shows  itself  in  patho- 
logical relations,  especially  in  melancholic  states,  sometimes 
"v\dthout  hallucinations.  Particularly  where  the  content  of  con- 
sciousness possesses  no  firm  and  resisting  texture,  confusion 
ma}'  be  easily  brought  on  by  an  emotion,  as,  e.g.,  in  inheritors, 
imbeciles,  alcoholists. 

4.  By  the  disintegration  of  the  consciousness  in  mental 
weakness,  as  the  demented  form  of  confusion,  which  is  observed 
in  terminal  dementia,  in  paresis,  in  senile  dementia,  and  other 
organic  brain  diseases. 

The  state  of  paraphasic  confusedness,  which  presents  the 
s^TQptom  of  a  focal  brain  disease,  is  to  be  distinguished  from 
confusion.  The  patient  is  confused  outwardly  because  he  uses 
words  whose  meanings  are  contrary  to  those  he  intended  using. 

The  fact  that  momentarily  certain  sense  perceptions,  cer- 
tain ideas,  certain  feelings  are  dominant  in  the  consciousness 
and  are  able  to  press  back  all  others,  is  designated  by  the  term, 
attention. 

On  this  rests  the  possibility  of  studpng  a  circumstance, 
of  observing,  and  of  undertaking  difficult  mental  operations. 
The  lack  of  attention  (aprosexia)  is  a  common  s^onptom  of 
imbecility  and  of  all  conditions  of  mental  weakness.  It  ap- 
pears especially  in  maniacal  states,  in  which  a  continual  digres- 
sion appears  as  a  characteristic  s^Tiiptom. 

The  attention  may  be  heightened  in  the  insane  by  the  con- 
centration of  the  consciousness  upon  certain  pathological  phe- 
nomena. Sometimes  the  hallucinated  pursue  their  hallucina- 
tions with  the  greatest  zeal;  hypochondriacs  pay  particular  at- 
tention to  the  phenomena  in  their  own  bodies,  sometimes  to  a 
certain  organ  of  the  body;  melancholiacs  and  paranoiacs,  to 


Di'sliirhdiiccs  of  Consciousness.  61 


events  of  the  external  world  brought  into  relationship  witli 
their  own  delusions  {hyperprosexia).  The  possibility  of  a  slight 
divergence  of  the  attention  shows  its  weakness,  but  does  not 
necessarily  signify  a  partial  phenomenon  of  general  mental 
weakness,  and  therefore  is  not  an  unfavorable  symptom.  The 
divergence  may  also  come  from  the  rapid  change  of  concentra- 
tion, to  the  slight  coherence  of  the  single  images  as  in  delirium 
hallucinatorium,  or  the  eversion  of  the  ideas  in  maniacal  states, 
and  does  not  imply  an  unfavorable  prognosis. 

The  physiological,  periodically  recurrent  diminution  of 
the  power  of  the  mental  processes  of  consciousness,  which  may 
reach  to  its  complete  loss,  as  in  unconsciousness  (sleep  without 
dreams),  is  sleep,  which  presents  very  probal)ly  a  physiological 
autointoxication  of  the  brain. 

Its  diminution  to  complete  sleeplessness  (agrypnia)  pre- 
sents one  of  the  most  common  initial  symptoms  of  mental  dis- 
ease and  quite  often  accompanies  the  curable  mental  disturb- 
ances throughout  their  whole  course.  The  return  of  sleep  is 
frequently  the  first  symptom  of  convalescence.  Defective  sleep 
exists  in  most  of  the  intoxication  psychoses,  while  it  is  gener- 
ally undisturbed  in  imbeciles  and  the  demented. 

An  abnormally  heightened  desire  for  sleep,  even  to  leth- 
argy, sometimes  takes  place  in  convalescence  from  the  psychoses, 
oftener  in  organic  mental  diseases,  paresis,  senile  dementia, 
.and  in  brain  tumors. 

Periodical  falling  asleep,  which  appears  without  reference 
to  time  and  place  (narcolepsia) ,  is  observed: — 

1.  In  epileptics.  The  narcoleptic  attack  here  signifies  an 
epileptic  equivalent. 

2.  In  the  hj'sterical,  sometimes  lasting  for  days  or  weeks. 
With  this  there  is  generally  trembling  of  the  eyelids  and 

a  certain  katatonic  rigidity  of  the  muscles. 

3.  In  apoplectics,  sometimes  as  a  premonitory  symptom  of 
attacks;  also  in  albuminuria  and  mellituria. 

In  the  transition  from  sleep  to  waking,  dream-ideas,  taken 
from  sleep,  and  in  which  there  is  not  yet  complete  conscious- 
ness, may  generate  a  state  of  sleep  drunkenness  (somnolentia) 
which  may  lead  to  perverted  and  even  violent  actions  along  the 
line  of  those  dream-ideas. 


62  General  Symptomatology. 

In  waking  states  clouding  of  the  consciousness  Avith  pres- 
ervation of  the  cajjabilities  of  motion  and  action  may  appear  as 
twilight  states,  and  with  its  limitation  or  loss  it  approaches  a 
stupor. 

1.  Twilight  States.^ 

The  term  '^"'twilight  states"  is  used  in  this  work  in  lien  of 
"subconscious  states." 

The  twilight  state  presents  such  a  want  of  clearness  of  the 
consciousness,  that  the  psychic  phenomena  which  are  being  com- 
pleted cannot  be  recognized  as  belonging  to  the  Ego.  The 
actions  performed  in  this  condition  are  comj)leted  under  the 
threshold  of  self -consciousness  by  means  of  images  of  memory, 
or,  if  we  take  into  consideration  the  well-worn  paths,  quite  often 
according  to  the  momentary  sense  perceptions.  The  ease  of 
their  elaboration  and  transition  into  actions  is  sufficiently  ex- 
plained by  the  lack  of  inhibitory  ideas. 

Such  a  patient  in  the  twilight  state  may  answer  the  com- 
mon questions  about  his  name,  his  age,  or  his  dwelling.  The 
physician  visits  him;  on  being  asked,  he  shows  his  tongue; 
when  questioned,  he  says  that  he  has  slept  during  the  night, 
has  a  good  appetite,  etc. ;  but  the  patient  has  really  answered 
in  the  twilight  condition  with  the  absence  of  his  self -conscious- 
ness. In  such  a  twilight  condition  the  patient  can  make  pur- 
chases, undertake  journeys,  count  money  correctly  and  pay  it 
out.  In  such  twilight  states  criminal  actions  are  sometimes 
executed,  desertion,  theft,  exhibitionism,  violent  injuries  to 
others  are  carried  out  apparently  with  a  full  understanding  of 
the  object  in  view.  With  the  frequent  return  of  such  states 
in  the  same  individual,  the  actions  performed  in  such  a  condi- 
tion may  appear  with  a  certain  uniformity  and  stereotyped 
character,  as  is  observed  especially  in  epileptic  twilight  states 
(psychical  epilepsy). 

The  pupils  in  epileptic  twilight  states  react  slowly  or  not 
at  all  to  light,  are  dilated  or  moderately  dilated.  The  color  of 
the  face  is  generally  pale.     Sometimes  in  a  hysterical  twilight 


^Morchen,  Aus  dei-  psychiatrischen  Klinik  zu  Marburg,  1901. 


Disturhaiues  of  Consciousness.  63 

state  the  answers  are  so  perverted  and  nonsensical  that  they 
give  the  impression  of  being  simulated   (Ganser). 

If  in  these  twiliglit  states  hallucinations  appear,  tliey  are 
designated  dream  states. 

The  duration  of  these  twilight  or  dream  states  may  vary 
between  the  fraction  of  a  minute  to  hours,  days,  weeks,  or  even 
months.  In  some  cases  amnesia  exists  during  the  whole  period 
of  the  attack.  Generally  the  recollection  of  the  phenomena  is 
only  obscured,  or  there  is  a  summary  recollection  with  the  loss 
of  the  details.  Only  exceptionally  is  there  a  complete  power 
of  recollection. 

The  patient  of  Bonhofer  spoke  of  his  actions  performed  in 
a  twilight  state  as  done  by  a  third  person. 

Twilight  states  appear  especially  often  in  epileptic  and 
alcoholic  psychoses.  In  the  latter  they  are  designated  as  trances. 
They  are  sometimes  observed  in  hysteric,  oftener  in  traumatic 
psychoses;  furthermore,  jn  certain  conditions  of  intoxication, 
e.g.,  in  uremia,  and,  finally,  in  organic  psychoses,  especially 
frequent  in  connection  with  paralytic  attacks  or  replacing  them. 
Exceptionally,  such  a  twilight  state  may  appear  transitorily  in 
very  severe  bodily  pain,  as,  e.g.,  in  migraine,  in  trigeminal 
neuralgia  {dysthymia  neuralgica,  Schiile). 

In  those  cases  in  which  these  twilight  states  appeal-  gen- 
erally at  night  with  wandering  about,  as  is  especially  observed 
in  epilepsy  and  hystero-epilepsy,  the  term  somnambulism  {som- 
namhtdare,  walking  in  sleep)  has  been  used.  Sometimes  in 
these  states  the  dominant  ideas  of  the  normal  waking  condi- 
tion are  forgotten,  but  return  to  the  patient  as  soon  as  the 
attack  recurs.  From  this,  the  patient  has  a  double  mental  life, 
a  condition  which  has  been  designated  by  the  name  of  double 
consciousness  (Jessen)  or  alternating  consciousness  (Solbrig), 

2.  Stupor.' 

With  the  diminution  of  the  lucidity  of  consciousness,  which 
may  l)e  present  in  very  different  degrees,  a  motor  disturbance 
enters,  the  patient  is  immovable,  rigid.  The  stupor  may  have 
very  different  bases,  and  offers,   conformably  to   them,   many 

'  Meyer,  Archiv  fiir  Psycliiatrie,  vol.  32,  p.  868,  1899. 


64  General  Symptomatology.- 

differences    in    external    appearance.     We    distinguish    the    fol- 
lowing kinds  of  stupor: — 

(a)   Anxious    Stupor. 

The  jDatient  is  rigid  from  anxiety.  The  expression  of  the 
coimtenance  is  full  of  pain  and  anguish,  with  open,  fixed  eyes; 
the  muscles  of  the  face  are  convulsivel}-  contracted.  The  pa- 
tient is  mute,  even  if  single  motions  of  the  lips  sometimes  show 
that  he  would  like  to  speak.  The  limbs,  which  are  held  with- 
out motion,  may  be  bent  without  much  resistance,  like  wax 
{flexibilitas  cerea).  The  patients  are  able  to  remain  in  cramped 
positions  for  a  long  time,  much  longer  than  they  could  in  the 
normal  condition,  a  fact  which  should  be  connected  with  the 
circumstance  that  the  patient  has  contemporaneously  lost  the 
feeling  of  fatigue,  and  even  the  feeling  of  hunger  and  thirst  is 
absent.  In  many  cases  the  motionless  condition  of  the  j)atient 
may  be  explained  by  Icatamnesia^  as  brought  forth  by  a  "com- 
mand." There  are  anesthesia  and  analgesia  of  the  skin,  excep- 
tionally,' hyperesthesia.  The  pulse  is  somewhat  slower,  the 
temperature  is  generally  subnormal. 

This  anxious  stupor  may  be  iDrought  on  by  melancholic, 
h5^pochondrie  or  paranoic  delusions.  In  reference  to  the 
first,  delusions  of  transgression  or  crimes  cause  the  patient  to 
become  rigid.  In  hypochondric  states  the  delusions  of  having 
no  longer  organs,  or  of  being  made  of  glass,  possess  the  patient. 
In  paranoic  delusions,  fear  of  enemies,  fear  of  betraying  his 
presence  to  his  enemies  by  a  movement,  etc.,  make  the  patient 
motionless.  Sometimes  paranoic  delusions  cause  him  to  think 
that  his  enemies  hold  his  tongue,  hands,  and  limbs. 

With  these  delusions  are  connected  in  most  cases  hallu- 
cinations, which  strengthen  the  anxiety  and  the  immovalnlity 
(delusional  stupor,  Xewington).  One  sees  his  children  slain 
before  his  eyes,  another  believes  that  he  is  in  the  midst  of  a 
conflagration,  a  third  is  in  a  battle  and  is  afraid  of  getting  into 
the  fire  or  encountering  a  hostile  sword  at  every  motion.  Some- 
times the  voice  of  God  calls  to  the  patient  not  to  move,  or  the 
voice  of  the  pursuer,  which  threatens  him  with  severe  punish- 
ment if  he  stirs. 

Anxious  stupor  appears  especially  in  melancholia,  but  is 


Disturbances  of  Consciousness.  65 


also  observed  in  delirium  hallucinatorium,  in  alcoholism,  in 
the  depressive  phases  of  paresis,  as  well  as  in  hysteria  and 
epilepsy.  It  sometimes  appears  in  the  last  as  a  post-hysteric 
or  post-epileptic  condition,  or  as  an  equivalent.  Disregarding 
the  epileptic  stupor,  after  which  the  memory  is  generally  much 
obscured  or  lacking  altogether,  in  the  other  cases  of  stupor  the 
memory  is  seldom  preserved  entire  and  is  often  considerably 
impaired.  Sometimes  the  stupor  passes  into  a  state  of  ex- 
cited confusion,  with  delirium,  which  is  then  followed  by  the 
condition  preceding  the  stupor. 

The  highest  degree  of  this  anxious  stupor  has  been  desig- 
nated from  antiquity  (C^lius  Aurelianus)  by  the  name  of 
catalepsy  (from  '  Kara  XafifBdveLv ,  to  seize  suddenly).  The 
patient  is  designated  as  stipitis  sive  trunci  instar  tnortui  ritu 
jacens. 

The  condition  of  catalepsy  may  also  be  artificially  induced 
in  predisposed  individuals,  by  hypnotism. 

(b)  The  Maniacal  Stupor. 

In  contrast  to  the  anxious  stupor,  the  conditions  of  which 
have  just  been  described,  there  are  rare  cases  of  very  peculiar 
religious  delusions  with  blissful  content:  of  being  in  Heaven, 
of  speaking  with  God,  of  the  patients  becoming  enraptured 
{ecstasy).  In  these  conditions  the  patients  appear  motionless 
dumb,  but  betray  their  internal  excitement  by  the  expression 
of  their  countenances.  This  maniacal  stupor  is  observed  espe- 
cially in  hysteric  and  epileptic  psychoses. 

(c)   The  Katatonic^  Stupor   (Negative  Stupor). 

The  arrest  of  motion  depends  here  upon  an  "obstruction" 
(Kraepelin).  This  obstruction  proceeds  from  hallucinations 
and  delusions ;  the  attempt  at  any  motion  is  suppressed  by  an- 
tagonistic motions.  The  patient  sits  or  lies  with  partly  closed 
blinking  eyes.  The  mouth  is  often  pushed  forward,  the  lips 
sometimes  are  pointed  like  a  proboscis  (snout  cramp).  The  head 
is  inclined  forward,  the  face  and  limbs  appear  rigid  like  those 


'^From    Kara  and    reivetv     (to  draw):  sudden  attack  of  a  state  of 
tension  of  the  muscles. 


66  General  Symptomatology. 

of  a  statue.  The  patient  is  mute  or  only  murmurs  single  unin- 
telligible words.  If  one  attempts  to  place  his  limbs  in  a  different 
position,  the  patient  resists,  and  if  overcome  the  extremities  re- 
turn very  Cjuickly  to  the  previous  position.  Often,  however,  they 
retain  the  extremities  in  the  position  artificially  given  them,  as 
was  described  in  the  anxious  form  of  stupor,  as  there  are 
generally  many  transitions  between  the  anxious  and  negative 
stupor,  and  sometimes  both  forms  may  be  seen  at  different  times 
in  the  same  patient.  Occasionally  in  this  condition  there  are 
quick,  sometimes  violent  movements,  swift  grasping  for  a  glass 
standing  beside  the  bed,  emptying  its  contents,  speaking  single 
words,  going  from  the  bed  to  the  door.  These  movements  show 
something  of  an  impulsive,  impellent  disposition,  and  have  a 
more  or  less  stereotyped  character. 

The  muscles  of  the  bod}',  especially  the  abdominal  muscles, 
particularly  the  recti  abdominis,  feel  tense.  As  in  the  stupor 
of  anxiety,  so  also  in  this  katatonic  stupor,  the  capability  of 
attention  is  often  present  to  a  considerable  extent,  if  not  so 
completely.  Hence  the  patients  are  able  to  report,  after  they 
have  recovered  from  the  stupor,  what  has  taken  place. 

This  last  fact  is  often  lost  sight  of  by  physicians  and 
attendants.  The  lethargic  and  apparently  indifferent  condi- 
tion in  which  the  patient  lies  causes  them  to  believe  that  he 
understands  nothing  at  all  of  what  is  said  in  his  presence  or 
what  may  be  done  there.  The  convalescent  prepares  disagreeable 
surprises  for  them  by  his  accounts  of  rough  or  unseemly  ut- 
terances or  actions,  occurring  near  him  while  he  lay  in  stupor. 
The  appearance  of  the  above-mentioned  impulsive  movements, 
in  which  the  patient  may  undertake  violent  actions  against  him- 
self, makes  it  necessary  that  those  in  a  stupor  condition  should 
be  constantly  and  carefully  watched  in  spite  of  their  apparent 
loss,  of  motion  and  incapability  of  action. 

The  katatonic  tension  may  be  referred  to  pathological 
changes  of  the  musciilar  feelings,  as  hallucinations  in 
the  muscular  and  kinesthetic  senses.  The  external  resistance 
which  is  shown  in  the  defensive  movements  of  negativism 
may  be  generally  referred  to  delusions,  especially  those  of 
a  h}-pochondric  and  paranoic  nature.  In  sporadic  cases, 
where  the  patients  had  had  "snout  cramp,''  they  informed  me 


Dislarhances  of  Consciousness.  67 


that  they  had  held  their  mouths  in  this  way  in  order  to  guard 
against  the  entrance  of  poisonous  substances. 

Sometimes,  also,  visual  or  auditory  hallucinations  force 
the  patients  to  resistance. 

Katatonic  stupor  appears  in  hypochondric  melancholia 
and  paranoia,  especially  at  the  time  of  puberty;  also  in  epilep- 
tics, in  paretics,  sometimes  in  delirium  hallucinatorium. 

(d)  The  Hypotonic  Stupor  (Anergic  Stupor,  Newington). 

In  these  cases  a  hypotonia  of  the  muscles  is  connected 
with  the  clouding  of  the  consciousness;  the  expression  of  the 
countenance  is  vacant,  idiotic,  the  muscles  of  the  face  are 
hypotonic  or  atonic.  The  mouth  is  closed,  the  lower  jaw  hangs, 
saliva  trickles  from  the  mouth,  and  pieces  of  food  placed  in  the 
mouth  remain  undisturbed,  stools  and  urine  pass  involuntarily. 

Every  movement  of  the  head,  trunk,  and  extremities  is 
allowed  to  be  carried  out  without  resistance.  After  the  cessa- 
tion of  the  mechanical  action,  the  body  or  the  agitated  member 
follows  the  law  of  gravitation  and  the  uplifted  arm  sinks  to 
the  side. 

This  form  of  stupor  appears  especially  clear  in  dementia 
acuta,  is  also  observed  as  a  post-epileptic  condition  and  after 
hysteric  attacks,  sometimes  after  paralytic  attacks  and  in  alco- 
holism. 

The  duration  of  the  stuporous  states  may  be  transitory 
for  minutes  or  hours  (especially  in  hysteric  or  epileptic  pa- 
tients, sometimes,  also,  in  paranoia  and  paresis),  but  may  be 
protracted  for  weeks  and  months. 

A  more  pronounced  loivering  of  the  consciousness,  even  to 
its  extinction,  takes  place  in  apoplectic  attacks,  in  epileptic 
seizures,  in  poisonings  (apoplectic  form  of  intoxication),  and 
constitutes,  with  its  different  degrees,  the  transition  to  death. 

We  distinguish  here  somnolence  as  the  lowest  degree,  fol- 
lowed by  sopor,  coma,  and,  finally,  carus.  There  is  no  exact 
demarcation  between  these  different  degrees  of  unconsciousness. 
We  generally  designate  as  sopor  that  degree  in  which  there  is 
still  a  reaction  and  a  short  transitory  state  of  awaking,  through 
strong  stimuli,  while  stimuli  have  absolutely  no  effect  in  coma. 

The  clouding  of  the  consciousness  may,  finally,  continue 


68  General  Symptomatology. 

with  such  a  heightened  agitation  that  it  forms  externall}-  the 
image  of  raving. 

We  distinguish: — 

1.  The  Maniacal  Form  of  Raving. 

The  jDatients  jump,  dance,  clap  their  hands,  sing,  laugh, 
weep,  cry  out,  cannot  be  kept  in  bed,  tear  their  clothes,  run 
around  naked,  drum  on  the  door,  strike  on  the  window-panes, 
run  against  the  doors,  destroy  what  is  not  nailed  fast,  seize 
persons  who  approach  them,  are  especially  eager  to  grab  spec- 
tacles, watch-chains,  strike  at  and  wound  those  about  them. 

This  is  a  j)sychomotor  impulsion,  which  generally  enters 
with  feelings  of  pleasure,  but  may  also  be  called  forth  and 
continued  by  emotions  of  anger. 

The  countenance  generally  shows  a  serene,  joyful  expres- 
sion, the  eyes  are  Cjuite  often  of  special  brilliancy.  Illusions 
are  seldom  wanting,  often  there  are  also  hallucinations,  espe- 
cially of  the  vision.  The  sensory  feelings  are  depressed  or 
wanting. 

The  purest  picture  of  this  maniacal  raving  is  shown  by 
mania  in  its  frenzied  stages,  sometimes  also  in  the  periodical 
form  of  the  same,  and  in  the  maniacal  stage  of  circular 
psychosis.  Further,  it  appears  in  delirium  hallucinatorium, 
often  in  the  maniacal  stage  of  paresis  (with  sluggishness  or 
rigidity  of  the  pupils,  disturbances  of  speech,  variation  of  the 
tendon  reflexes,  apoplectiform  attacks),  in  intoxication 
psychoses,  in  hj^steric  and  epileptic  psychoses. 

2.  The  Anxious  Form  of  Raving. 

The  patients  cry  out,  lament,  howl,  call  ''help,"  "fire," 
"air,"  "I  stifle,"  tear  off  their  clothing,  destroy  ever3'thing 
which  is  near  them,  injure  themselves  and  others  severely. 

Meanwhile  their  faces  wear  a  much-distorted,  anxious  ex- 
pression. 

Illusions  or  hallucinations  are  never  lacking  here. 

This  raving  state  may  represent  the  highest  degree  of  an 
anxious  melancholia;  it  appears  intercurrently  as  the  acute 
heightening  of  melancholic  anxiety,  as  raptus  melancholicus ; 
appears  in  h}"pochondric   melancholia,   with   anxiety   that   the 


Disturbances  of  Sclf-Cunsciousness.  09 


air  is  poisoned,  that  death  must  come  at  once.  Even  paranoiacs 
may  become  raving  temporarily  in  the  anxiety  wliich  the 
anguish  from  their  persecutors  brings  on. 

Further,  anxious  raving  appears  in  paresis  (mehmcholo- 
hypochondric  stage),  in  senile  dementia,  in  delirium  hallu- 
cinatorium,  and  in  various  intoxications,  especially  in  the  stage 
of  abstinence    (alcoholism,  morphinism). 

Eaving  epileptics  belong,  together  with  raving  alcoholists, 
with  the  most  dangerous  of  the  insane;  in  epilepsy  anxious  rav- 
ing o'ften  appears  as  a  post-epileptic  psychosis,  sometimes,  also, 
as  an  equivalent. 

The  attacks  of  raving  may  pass  off  in  a  few  minutes  (see 
mania  transitoria),  especially  the  anxious  form,  but  may  last 
hours,  days,  or  even  many  months;  they  may,  however,  continue 
indefinitely,  with  short  remissions. 

A  quick  transition  to  death  is  observed  in  the  raving  of 
so-called  delirium  acutum. 

Twilight  states,  stupor,  and  raving  may  interchange  in 
the  same  person,  that  is,  they  may  pass  from  one  condition 
into  another;  stupor  may  follow  the  twilight  state,  raving  may 
follow  the  stupor,  and  inversely. 

Sometimes  a  deep  sleep  is  the  conclusion  of  the  former 
condition  (often  in  epileptic,  less  often  and  less  marked  in 
hysteric  psychoses). 


VII.  THE  DISTURBANCES  OF  SELF-CONSCIOUSNESS 

appear : — 

1.  As  a  deficient  or  abnormal  development  of  itself,  as  in 
imbeciles  and  idiots.  As  it  is  generally  impossible  for  these 
patients  to  create  conceptions  by  their  own  mental  processes, 
they  succeeed  still  less  in  the  creation  of  an  Ego. 

2.  A  normal  self -consciousness  can  exist  only  in  the  normal 
clearness  of  the  consciousness.  According  to  this,  the  last  must 
be  disturbed  in  all  pathological  conditions  in  which  its  clear- 
ness is  lacking  and  of  which  we  spoke  just  now. 

3.  A  falsification  of  the  self-consciousness  must  appear 
where  the  content  of  the  consciousness  is  falsified,  not  transi- 


70  General  Sympiomatology. 

torily,  but  repeated!}'.  In  the  struggle  of  the  Ego,  which  often 
takes  place  at  first  against  such  falsifications,  it  is  finally  con- 
quered if  the  disease  continues.  From  the  falsification  of  the 
consciousness  those  cases  are  developed  in  which  the  patient 
believes  that  another  person  is  concealed  in  himself,  an  "alter 
ego,"  who  guides  or  inliibits  his  actions,  who  holds  his  tongue 
firmly,  speaks  in  him  (dujjlication  of  the  personality'). 

4.  If  the  pillars  of  consciousness  on  which  the  Ego  con- 
ception has  been  built  are  destroyed,  the  self-consciousness  crum- 
bles, and,  finally,  we  come  to  the  destruction  of  the  personality 
(mental  weakness  to  the  highest  degree  of  dementia). 

5.  Where  unconsciousness  exists  there  can,  of  course,  be 
no  self -consciousness.  But,  on  the  contrary,  there  may  be  con- 
sciousness, even  if  it  be  falsified  and  pathological,  while  self- 
consciousness  is  lacking.  In  pathological  conditions  a  con- 
sciousness, that  is,  a  self-completion  of  mental  details,  may  be 
present,  and  is  present  in  the  different  twilight  states,  while 
self-consciousness  is  lost. 

Since  the  essential  content  of  self-consciousness  consists 
in  the  relation  of  the  Ego  to  the  outer  world,  the  disturbances 
of  the  self-consciousness  will  manifest  themselves  externally  in 
the  anomalies  of  the  actions. 

A  considerable  part  of  these  disturbances  in  the  sense  per- 
ceptions, in  thought  and  the  feelings,  and  in  the  content  of 
consciousness  may  be  present  occasionally  and  transitorily. 
single  ones  even  persistently,  without  there  being  any  mental 
disease.  But  if  there  is  a  persistent  disturbance  of  the  self- 
consciousness,  it  is  an  absolute  proof  of  insanity. 


VIII.  THE  DISTURBANCES  OF  ACTION. 

1.  Reflex  Actions. 

Eeflex  actions  in  which  the  iucitation,  without  the  assist- 
ance of  other  ideas  present  in  the  consciousness,  but  especially 
without  the  aid  of  those  which  are  to  a  marked  degree  accentu- 
ated in  the  self-consciousness  and  constitute  the  personality 
producing  the  action,  are  present  in  the  insane  in  a  much  more 
extended  degree  than  in  the  normal  individual. 


Disturbances  of  Action.  71 


The  incitatiou  may  act  by  a  sense  perception,  in  a  real  or 
hallucinated  idea,  or  one  called  forth  momentarily  by  that,  or 
in  an  idea  of  memory,  in  a  feeling,  in  the  momentary  content 
of  the  consciousness  which  is  falsified  by  hallucinations  and 
delusions.  If  the  sense  feelings  form  the  impulse,  we  speak  of 
instincts  and  designate  the  actions  as  instinctive  actions.  If 
especially  strong  feelings  of  pleasure  or  disj^leasure  are  the 
point  of  departure,  wc  call  the  actions  thence  proceeding 
emotional  actions,  whose  reflex  nature  is  also  shown  in  the  ex- 
ternal image  of  what  is  found  in  the  emotion. 

Such  reflex  actions  appear  in  the  insane: — 

(a)  From  the  weakness  of  the  contrasting  ideas  contained 
in  the  self-consciousness,  so  in  all  states  of  mental  weakness. 
So  far  as  immodest  actions  are  observed,  their  carrying  out 
is  favored  by  defective  development,  laxity,  or  disappearance 
of  the  feelings  of  judgment. 

A  part  of  the  actions  arising  on  the  basis  of  so-called  moral 
insanity  are  to  be  considered  reflex  actions,  which  have  been 
excited  by  momentary  stimuli  or  emotions  and  are  transformed 
into  actions  without  inhibition. 

(&)  With  clouding  of  the  consciousness;  thus,  in  the  twi- 
light states  in  which  the  capability  of  action  is  retained,  the 
momentary  sense-impression  is  transformed  into  an  action,  or 
an  occupation  already  engaged  in  before  the  beginning  of  the 
morbid  state,  which  is  continued  (the  musician  continues  play- 
ing, the  tailor  continues  sewing,  etc.).  Also,  an  idea,  reproduced 
in  the  condition  of  the  elimination  of  consciousness,  may  evoke  a 
deed  which  would  have  remained  undone  in  normal  states  of 
the  consciousness,  from  the  resistance  of  the  self-consciousness. 
From  this,  the  carrying  out  of  an  action  does  not  show  its 
responsibility  as  being  inspired  by  the  relations  of  the  person, 
perhaps  its  carrying  out  was  designed.^ 

These  actions  are  observed  especially  in  epileptics  and 
alcoholists,  sometimes  also  in  hysteric  twilight  states  (which  see). 

If  the  clouding  of  the  consciousness,  as  in  maniacal  raving, 
is  connected  with  an  unnatural  excitement  of  the  movement 
impulses,  the  incitations  appearing  in  the  sensory  and  sensorial 


Moeli,  Zeitscluift  fiir  Psychiatric,  vol.  Ivii,  169,  1900. 


72  General  Symptomatology. 

spheres  become  released  so  much  the  easier  in  reflex  actions, 
and  even  in  those  of  a  violent  character.  In  anxious  raving  the 
actions  correspond  to  the  incitation  in  a  brain  having  immod- 
erate emotion. 

(c)  In  the  manner  of  tics,  as  we  know  them  in  hysteria 
and  chorea,  as,  e.g.,  onomatomania  and  coprolalia,  there  arise  in 
the  insane,  in  consequence  of  feelings  appearing  momentarily  (es- 
pecially feelings  of  the  muscles)  or  ideas,  a  reflex  ejaculation 
of  words,  determined  movements  and  determined  actions.  Some 
of  the  so-called  automatic  movements  rest  on  the  reflex  unfold- 
ing of  determined  returning  feelings. 

{d)  With  falsification  of  the  content  of  the  consciousness, 
but  with  outer  circumspection  preserved,  a  sense-perception, 
entering  momentarily  with  the  lively  emotion,  may  transform 
this  at  once  into  an  action.  The  paranoiac  who  is  hallucinated 
hears,  while  walking,  an  abusive  word  uttered;  a  box  on  the 
ear  follows  this  immediately.  A  paranoiac  sees  a  person,  who 
is  approaching  him  on  the  street,  spit,  and  he  at  once  strikes 
at  him. 

(e)  The  easy  entrance  of  the  reflex  actions,  finally,  dis- 
tinguishes a  series  of  men,  belonging  in  the  class  of  inheritors, 
who  stand  on  the  border-land  between  mental  health  and  men- 
tal disease.  The  suddenness,  cpiite  often  violence,  of  their 
actions,  which  follow  immediately  the  sensorial  incitation,  im- 
pulse, emotion,  or  the  idea  of  memory  suddenly  appearing  at 
that  instant,  shows  that  they  do  not  possess  an  intermediate 
stage  of  consideration  and  deliberation  between  the  stimulus 
and  the  action. 


2.  The  So-called  Arbitrary  Actions. 

(a)  Pathological  Heightening  of  the  Activity   (Hyperkinesis). 

This  sometimes  shows  itself  on  the  border-lands  of 
psychoses  in  inheritors  in  the  morbid  desire  to  begin  every- 
thing, to  exercise  their  powers  with  the  greatest  energy,  to-day 
here,  to-morrow  there.  Xothing  ends  profitably,  from  the  un- 
steadiness and  variability  of  their  exertions. 

In  the  insane  the  pressure  of  acti^'ity  is  shown  very  purely 


Disturbances  of  Action.  73 


in  hypomania,  then  in  all  maniacal  states,  especially  in  mania 
and  without  inhibition,  especially,  however,  without  inhibition 
by  the  obstructing  muscular  feelings  of  fatigue,  in  maniacal  rav- 
ing. This  is  also  true  of  the  maniacal  stage  of  circular 
psychosis  and  of  that  of  paresis. 

The  anxious  form  of  raving  shows  the  heightened  activity 
in  movements  for  defense  against  the  hallucinations  and  delu- 
sive images  called  forth  by  anxiety,  or  only  as  an  outburst  of 
anxiety  externally. 

The  heightened  activity  of  the  restless,  versatile  idiot,  of 
the  demented,  belonging  to  the  type  of  chronic  mania,  and  of 
many  katatonic  states,  calls  forth,  in  connection  with  the  con- 
dition of  mental  weakness,  many  of  the  stereotyped  forms  of 
movements,  as  somersaults,  jumping  up  and  down  from  a  chair, 
rolling  about  on  the  earth,  incessant  knocking  on  the  door. 

(b)  Pathological  Diminution  of  the  Activity  Even  to  Its 
Destruction  (Akinesis). 

This  may  be  conditioned : — 

1.  By  stupor  (see  this).  The  paralysis  of  the  motor  ap- 
paratus excludes  the  capability  of  action,  or,  at  least,  limits  it 
considerably. 

2.  By  opposition  to  every  commanded  action  or  any  pre- 
sented by  circumstances  (negativism). 

The  patient  does  not  open  his  eyes,  does  not  open  his 
mouth  to  eat,  neither  voluntarily  nor  when  force  is  used ;  he 
will  not  move  from  the  spot  where  he  is.  This  negativism 
sometimes  corresponds  with  a  heightened  obstinancy,  as  it 
appears  in  children  who  are  not  mentally  diseased,  and  is 
quite  often  based  on  a  certain  fear  (obstinate  children  who  will 
not  show  their  tongues  to  the  physician,  who  shut  their  eyes 
from  fear  that  they  may  suffer  some  pain,  etc.).  In  other 
cases  this  negativism  rests  on  a  pathological  change  of  the 
muscular  feelings,  consequently  on  an  incitation  to  antagonism 
in  the  requisition  of  a  certain  muscle  necessary  for  a  certain 
motion.  Finally,  the  influence  of  hallucinations,  especially 
hallucinations  of  hearing,  are  often  decisive  for  negativism. 
'"'If  you  move,  yovL  are  dead,"  or,  in  the  presence  of  hypochon- 


74  General  Symptomatology. 

dric  delusions,  the  fear  of  being  shattered,  because  the  patients 
believe  that  they  are  made  of  glass. 

3.  By  general  inhibition,  as  it  appears  in  the  melancholic 
states  and  which  is  based  on  psychic  pain.  Each  mental  ac- 
tivity, each  initiative  tending  toward  bodily  activity,  provokes 
pain  or  heightens  that  already  present. 

4.  By  sense-deception  and  delusions. 

The  hypochondrically  insane  patient  cannot  be  brought 
to  any  exertion,  because  he  believes  that  his  organs  are  de- 
stroyed, his  hands  and  legs  paralyzed,  because  he  cannot  think. 
Delusions  of  negation  ("I  do  not  exist,''  "there  is  no  world") 
are  followed  by  absolute  inactivity.  Auditor}-  hallucinations 
may  jDrohibit  ever}'  activit}'  as  well  as  every  movement  for  the 
patient;  paranoic  delusions  force  him  sometimes  to  the  most 
dissimilar  positions,  in  which  he  remains  immovable. 

In  most  cases,  morbid  lying  in  bed  is  based  on  hypochon- 
dro-h3^steric  delusions.  The  patient  will  not  leave  his  bed 
because  he  fears  that  he  will  injure  his  health  out  of  it,  or 
because  every  movement  causes  pain. 

5.  The  faulty  development  of  the  intelligence  and  the 
diminution  of  previous  existing  intelligence,  the  lack  of  ideas 
emphasized  with  sufficient  power  to  induce  a  motor  expression 
corresponding  to  themselves,  lead  to  the  limitation  of  every 
activity  and,  finally,  to  incapability  of  action.  There  remain 
certain  conventional  expressions  which  are  perfected  by  well- 
worn  paths,  which  sometimes  ma}''  take  the  character  of 
stereotyped  actions,  repeated  without  object;  furthermore,  an 
imitation  of  what  has  been  shown  or  done  before,  oljjectless 
repetition  of  single  words  or  sentences;  finally  such  actions  as 
are  necessary  for  the  gratification  of  sensual  feelings. 

These  also  vanish  finally,  and  every  activity  is  destroyed 
in  apathetic  idiocy,  with  or  without  motor  paralysis. 

(c)   Qualitative   Changes  of  the   Activity. 

So  far  as  these  do  not  belong  under  (a)  Hyperl-inesis  and 
(b)  under  the  phenomenon  of  AhinesiSj  qualitative  changes  in 
action  are  shown: — 

1.  In  the  disease  of  certain  sense  centers  with  the  phe- 
nomena  of  word-deafness,   paraphasia,   paralexia,   paragraphia, 


Disturbances  of  Action.  75 


parapraxia  (change  of  the  usual  articles  of  use),  paramimia 
(not  the  tone  of  the  corresponding  expression  of  the  counte- 
nance) . 

2.  In  tJie  state  of  confusion  (see  VI.  The  Disturbances 
of  the  Consciousness). 

3.  By  a  fixed  direction  of  the  action,  which  is  given  l^y 
determined  hallucinations  or  delusions  (suicide  in  the  inelan- 
clioliacs,  morbid  extravagance  in  the  megalomaniacs,  persecu- 
tion in  the  paranoiacs,  all  kinds  of  defensive  actions  in  the 
hypochondriacs  [blowing,  spitting,  etc.] ) .  The  actions  arising 
in  this  manner  sometimes  assume  peculiar  forms,  according  to 
the  developing  mental  weakness  or  to  that  already  present, 
which  appear  as  habitual  movements  with  peculiar  manners 
(Kraepelin)  :  hoiD^Ding,  stretching  straight  forward  the  stiff 
hand  to  shake  hands,  taking  a  spoon  by  the  extreme  end,  disor- 
dered clothing,  peculiar  attire. 

4.  In  the  circumstances  which  have  been  designated  as 
moral  insanity. 

The  analysis  of  the  striking  actions  of  the  insane  is  an 
important  task  of  clinical  observation.  Frequently  enough  the 
report  of  the  convalescent  shows  how  well  motived  the  appar- 
ently "senseless"  actions  were  from  the  standpoint  of  the  pa- 
tient. But  this  analysis  is  especially  the  task  of  the  specialist 
in  forensic  medicine. 

An  example  may  be  given  here. 

Tlieft  may  be  commited  by  the  insane  under  the  following 
conditions : — 

1.  As  a  reflex  act: — 

(a)  In  states  of  mental  iveahness:  the  imbecile,  the  paretic, 
the  senile  dement,  the  epileptic  or  alcoholic  weak-minded  per- 
son takes  a  gold  piece  which  lies  before  him,  the  sausage  which 
hangs  bfore  the  butcher's  shop,  the  fruit  which  is  offered  for 
sale  in  the  streets;  the  act  follows  the  impulse  of  the  thought, 
and  it  is  not  obstructed  by  opposing  ethical  ideas.  In  many 
such  patients,  especially  in  paretics'  and  the  senile  weak- 
minded,  this  reaches  as  far  as  the  taking  of  all  possible  things, 
even  the  most  worthless,  as  cigar  stumps,  paper  cuttings,  and 
like  objects  {propensity  for  collecting). 

(h)   In   the    twilight   states,   especially    in   the    epileptoid 


76  General  Symptomatology. 


seizures  of  epileptics  or  jDaretics,  or  in  the  twilight  states  fol- 
lowing epileptic  seizures,  the  patients  steal,  either  on  the  basis 
of  a  momentary  sense  irritation,  or  on  the  ground  of  a  repro- 
duced idea  which  at  its  first  ajDpearance  caused  the  possession  of 
the  article  to  be  stolen  to  seem  desirable,  or  the  carrying  out 
of  the  theft  was  already  contained  in  the  idea.  From  this 
often  proceed  important  thefts  with  burglary.  There  exists 
in  all  of  these  cases  either  partial  or  total  amnesia. 

(c)  In  hysteric  psychoses  tic-like  thefts  occur  quite  fre- 
quently, often  after  a  short  transitory  state  of  anxiety,  or  the 
resolution  of  one;  the  tic-like  thefts  of  the  pregnant  form  a 
stepping-stone  to  a  psychopathic  condition. 

The  stolen  articles  are  often  useless,  they  are  often  thrown 
aside,  quite  often  returned  to  the  owner.  A  certain  part  of 
shop-lifting  belongs  in  this  category.  The  advent  of  these  tics 
is  favored  by  an  existing  menstruation. 

2.  As  so-called  arbitrary  actions. 

(a)  In  the  maniacal  condition^  in  hypomania,  mania, 
periodical  mania,  in  the  maniacal  stage  of  circular  psychosis, 
the  taking  away,  sometimes  violently,  of  articles  is  the  expres- 
sion of  the  universal  impulse  to  activity.  With  the  rapidity  of 
the  efflux  of  the  ideas  the  contrasting  ideas  do  not  appear  at 
all,  or  not  with  sufficient  force. 

(&)  In  the  state  of  confusion  thefts  may  be  perpetrated, 
besides  all  sorts  of  other  disorderly  actions. 

(c)  Delusions  may  be  the  cause  of  thefts  in  various  ways. 
The  paranoiac  steals  to  revenge  himself  on  the  world  or  on  a 
certain  person  who  has  injured  him  and  continues  to  injure 
him.  Another  paranoiac  steals  to  show  that  he  is  the  second 
Messiah  and  can  do  everything  without  discovery.  The  paretic 
in  megalomania  takes  things  because  everything  belongs  to  him, 
since  he  is  the  ruler  of  the  world;  he  steals  in  order  to  make 
another  a  present,  and  wonders  why  so  much  uproar  is  made 
about  it. 

(d)  With  the  morally  insane  the  desire  for  stealing  some- 
times appears  even  in  childhood :  "He  steals  like  a  raven,  we 
cannot  leave  anything  around."  The  ordinary  thief  is  some- 
times recruited  from  these  patients  after  they  have  shown  their 
incapacity  for  getting  along  in  an  honest  way. 


Disturbances  of  Speech  and  Writing.  77 

(e)  Sometimes  certain  viorhid  sensual  imjmlses  give  rise 
to  thefts,  as  in  feticliism. 

In  a  case  I  observed  an  elderly,  well-to-do  man  was  caught 
in  the  act  of  taking  the  white  handkerchief  from  a  woman's 
gown.  A  search  of  his  house  (the  man  was  a  widower)  revealed 
eighty-seven  handkerchiefs  which  he  had  stolen  at  different 
times,  since  he  could  only  practice  onanism  with  the  white 
handkerchiefs  which  had  been  used  by  women.  This  occurred 
in  a  man  mentally  weak  after  cerebral  apoplexy. 

In  a  similar  way  the  most  varied  criminal  actions,  e.g., 
arson,  by  those  mentally  diseased,  may  be  analyzed. 


IX.    THE    DISTURBANCES    OF    SPEECH,    WRITING, 
AND  THE  EXPRESSION  OF  THE  COUNTENANCE. 

1,  Some  of  the  insane  do  not  speak.  The  loss  of  speech 
may  be  conditioned : — 

(a)  By  the  lack  of  ideas,  or,  at  least,  of  ideas  powerful 
enough  to  seek  utterance  in  speech  (alogia). 

This  is  found  in  idiocy  and  apathetic  amentia. 

(&)  Bj  a,  state  of  stupor. 

(Here  sometimes  from  the  lack  of  the  capability  of  syn- 
thesis :  'T  did  not  know  what  I  ought  to  say.") 

(c)  By  sense  deceptions  and  delusions. 

The  patient  considers  that  he  is  not  worthy  of  speaking; 
he  fears  injuring  some  one  if  he  should  speak,  fears  to  commit 
lese  majeste  (melancholic  delusions),  or  believes  that  he  has 
no  tongue,  no  larynx  (delusion  of  negation),  or  that  these  are 
held  fast  by  a  hostile  power,  or  that  he  would  betray  his  pres- 
ence to  his  enemies  by  speaking  (paranoic  mania) , 

We  designate  this  farced  mutism  as  mutacism. 

(d)  By  a  hysteric  anesthesia  in  the  region  of  the  vocal 
apparatus,  similar  to  the  condition  present  in  hysteric  amau- 
rosis, in  hysteric  deafness,  etc.,  which  causes  in  the  patient  the 
idea  that  he  cannot  move  the  vocal  cords — hysteric  mutism  in 
hysteric  and  hystero-epileptic  psychoses. 

(e)  By  faulty  development  of  the  motor  speech  center 
in  consequence  of  faulty  development  of  the  auditory  center 


78  General  Symptomatology. 

(deaf -mutism),  or  in  consequence  of  disease  or  destruction  of 
the  motor  speech  center  (motor  aphasia). 

The  first  appears  in  idiots  and  imbeciles,  sometimes,  also, 
in  deaf  mutes  who  have  become  insane  in  later  life;  the  last 
as  a  focal  phenomenon  in  various  organic  psychoses. 

(/)  By  the  destruction  of  the  motor  conduits  for  the 
muscular  contractions  which  are  necessary  for  speech — 
anarthritic  deafness  (in  the  most  various  organic  psychoses; 
paresis,  senile  dementia,  post-apoplectic  psychosis). 

2.  In  those  insane  individuals  who  do  talk,  a  pathological 
change  of  the  speeech  may  be  conditioned: — 

(a)  By  the  morhid  disturbance  of  the  ideas. 

This  is  especially  strikingly  shown  in  the  states  of  confu- 
sion in  which  the  associations  occur  without  law  or  order,  and, 
corresponding  to  this,  the  words  are  intermingled  in  wild  con- 
fusion. 

It  is  the  same  when  the  associations  are  arranged  entirely 
according  to  the  sound  of  the  words  (tea,  Themis,  Themis- 
tocles),  or  according  to  certain  external  landmarks  (song,  opera 
house),  or  are  spoken  in  forced  rhymes  (especially  frequent  in 
maniacal  states,  also  in  acute  intoxications,  especially  alco- 
holic intoxication). 

Further,  the  speech  will  be  abnormal  by  the  expression 
of  delusions  (dysphrasia  vesana). 

Here,  sometimes,  it  reaches,  especially  in  paranoia,  but 
also  in  delirium  hallucinatorium,  in  alcoholism,  in  paresis,  gen- 
erally in  connection  with  auditory  hallucinations,  to  the  form- 
ing of  new  words — neologism  ("creator  of  chronixils,"  "akus- 
matic,"  "foscileur,"  etc.) — or  to  peculiar  nonsensical  connec- 
tions of  a  series  of  adjectives  with  a  noun:  "singing,  il3"ing, 
roaring  air  pressure.'^ 

In  sporadic  cases  the  anomaly  of  speech  is  shown  in  speak- 
ing a  foreign  language  sometimes  very  well  instead  of  the  mother 
tongue.  One  of  my  female  patients  with  periodic  mania 
spoke  only  French  during  the  attack;  a  female  teacher  in  a 
common  school  did  the  same  during  a  hysteric  psychosis;  a 
paretic,  who  had  spoken  only  High  German  before,  spoke  only 
Piatt  Deutsch  from  the  beginning  of  his  disease. 

(h)  By  pathological   disturbance  in   the   ideas,  connected 


Disturhances  of  Speech  and  Writing.  79 

with  irritation  or  paralytic  phenomena  in  the  cortical  speech 
center. 

To  the  irritation  states  1)elong  verbigeration  (Kahlbaum)  : 
Contmual  repetition  of  single  words  or  phrases;  sometimes  they 
are  exj^ressed  with  peculiar  gestures  and  grimaces,  with  or 
without  rhythm,  oftener  with  a  certain  pathos  which  is  specially 
distinguished  by  nonsensical  repetition. 

Verbigeration  is  observed  in  katatonic  conditions,  in  epi- 
leptic and  alcoholic  deliria,  in  paresis,  especially  after  paralytic 
attacks,  also  in  senile  dementia.  We  assume  that  here  an  irri- 
tative condition  in  the  speech  center  causes  the  repetition  of 
the  same  words  and  sentences,  just  as  in  a  form  of  echolalia, 
in  which  the  patient  repeats  what  he  has  just  heard.  This 
echolalia  appearing  in  choreic  psychoses,  but  also  in  katatonic 
states,  is  to  be  distinguished  from  the  echolalia  in  the  demented, 
which  will  soon  be  discussed.  A  state  of  irritation  in  the 
speech  center  also  exists  in  hallucinatory  echo-speech,  in  whicli 
the  patient  is  obliged  to  repeat  the  word  of  his  hallucination. 

A  paretic  condition  of  the  speech  center,  on  the  contrary, 
must  be  assumed  in  perseveration  (Neisser).  There  is  here  an 
adherence  of  the  appropriate  motor  idea  in  the  speech  center, 
the  patient  answers  the  first  question  correctly,  but  gives  the 
same  answer  to  the  following  questions.  Sometimes  even  the 
first  answer  is  incorrect. 

Perseveration  is  often  found  in  the  course  of  aphasia,  and 
a  transition  to  it  is  found  in  the  physiological  intercalation  of 
single  words  or  syllables  in  speech  (angophrasia,  Kussmaul). 
Perseveration  appears  in  the  same  mental  conditions  as  verbi- 
geration, sometimes  it  alternates  with  this.  It  is  also  ob- 
served in  twilight  states,  with  brain  tumors,  in  paresis  and 
senile  dementia,  mostly  in  consequence  of  paralytic  attacks. 

(c)  By  pathological  processes  in  the  speech  center.  The 
echo  speech  of  the  demented  shows  a  reflex  from  the  auditory 
center  to  the  speech  center.  Such  patients  echo  what  they  have 
just  heard  like  a  phonograph.  As  an  irritative  condition  in 
the  speech  apparatus  (tic)  is  to  be  considered,  especially  in 
choreic  and  epileptic  psychoses,  the  ejaculation  of  single 
words  (onomatomania — where  the  words  have  an  obscene  sig- 
nificance:   coprolalia)     (onomatomania    in    those    psychically 


80  General  Symptomatology . 

normal  generally  rests  on  habit,  e.g.,  uttering  the  word  which 
is  "uncalled  for").  The  'paralytic  states  in  the  sensorial 
speech  show  themselves  as  word-deafness,  where,  on  account  of 
the  faulty  comprehension  of  the  question,  the  answer  given 
may  appear  wholly  nonsensical,  or  is  changed  by  paraphasia. 

Word-deafness,  with  or  without  paraphasia,  is  sometimes 
erroneously  diagnosed  as  psychosis  with  confusion.  The  pa- 
tient who,  in  consequence  of  his  word-deafness,  answers  the 
questions  asked  him  in  a  nonsensical  way,  and  who  performs 
the  most  foolish  actions  through  his  inability  to  recognize  ob- 
jects, their  significance  and  use,  a  condition  quite  often  con- 
nected with  word-deafness,  as  sticking  the  comb  in  his  mouth, 
trying  to  eat  soup  with  his  fingers,  and  similar  acts — is  often 
considered  insane,  whereas  the  condition  is  one  of  focal  disease  of 
the  brain.  Thorough  examination  of  his  mental  status  and  of 
the  peripheral  nervous  system  (dexter  hemiparesis),  and  the 
apoplectic  onset  of  the  disease,  will  confirm  the  diagnosis  of 
focal  disease.  Intercurrent  and  complicating  them,  such  states 
enter  into  the  organic  psychoses,  in  brain  tumors,  in  syphilitic 
psychoses,  and  in  paresis. 

{d)  In  regard  to  the  iinnatural  efflux  of  speech,  we  distin- 
guish excessively  rapid  speaking  (logorrhea)  even  to  delirium 
of  the  tongue  (tumultus  sermonis),  especially  present  in 
maniacal  states.  The  opposite  of  this  is  constituted  by  speak- 
ing too  slowly  (bradyphrasia),  present  especially  in  melan- 
choliacs,  in  katatonic  states,  in  paresis,  in  brain  tumors,  and  in 
terminal  dementia. 

(e)  The  change  of  the  grammatical  construction  of  the 
sentence  {agrammatism,  ahataphasia)  is  shown  by  the  use  of 
the  infinitive,  or  the  patient  leaves  out  the  conjunctions,  he 
changes  the  prepositions,  the  pronouns.  Present  especially 
in  idiotism  and  in  organic  psychoses  with  aphasic  disturbances. 

(/)  Finally,  stuttering  {dysarthria  syllaharis)  and  stam- 
mering {dysarthria  literalis)  are  to  be  mentioned  in  this  connec- 
tion. In  the  latter  one  consonant  is  used  in  place  of  another, 
preferably  in  the  place' of  r  (pararhotacism)  or  of  s  (parasig- 
matism)  an  1,  w  or  f,  g.  Stuttering  and  stammering  are  espe- 
cially observed  in  idiotism,  stammering,  also,  in  organic 
psychoses,  especially  after  apoplectic  attacks. 


Disturbances  of  Speech  and  Writing.  81 


(g)  The  tone  of  the  voice  is  sometimes  weak,  lisping,  mo- 
notonous, especially  in  anxious  states,  sometimes  rough,  loud, 
especially  in  maniacal  states  in  consequence  of  the  imperfect 
closing  of  the  vocal  cleft.  It  is  nasal,  in  paralysis  of  the  velum 
palati;  deep,  in  laxity  and  atrophy  of  the  vocal  chords  (organic 
psychoses,  especially  paresis)  ;  bleating  (egophony),  in  hysteric 
psychoses. 

A  particularly  complicated  kind  of  speech  disturbance  is 
shown  by  paretics  and  will  be  discussed  fully  in  the  chapter  on 
paresis. 

3.  The  writing^  of  the  insane  in  regard  to  its  content  is 
formed  according  to  their  speech. 

Their  specimens  of  writing  are  sometimes  especially  valu- 
able, because  many  patients  confide  to  paper  what  they  are 
afraid  to  speak  (especially  in  hallucinations). 

The  emphasis,  underscoring  of  certain  words  often  point 
out  the  dominant  system  of  insanity,  which  may  also  be  ex- 
pressed in  cabalistic  signs,  in  cipher,  and  the  like. 

Verbigeration  and  perseveration  are  expressed  on  paper  as 
in  speech. 

Oftener  the  first  lines  of  the  writing  are  intact  in  content, 
and  first  show  the  pathological  disturbance  further  on. 

In  connection  with  delusions  and  hallucinations,  sometimes 
an  obsession  to  write  appears.  The  patient  asserts  that  another 
guides  his  hand  and  forces  him  to  write  certain  words  or  sen- 
tences of  which  he  knows  nothing  himself  and  which  he  does 
not  wish  to  write. 

The  maniacal  state  is  shown  in  the  form  of  the  writing, 
viz.,  by  many  underscorings,  by  numerous  exclamations,  by  direc- 
tions :  "per  the  tube  post,"  "per  the  express  messenger,"  by  blots 
and  other  stains ;  the  micromaniacs,  sometimes  by  the  very  small 
writing;  the  paranoiacs,  especially  in  querulant  insanity,  by 
massiveness  and  thoroughness,  by  neologisms;  the  paretics,  by 
leaving  out  letters  and  syllables  or  their  transposition,  and  by 
syllable-stumbling.  Finally,  it  culminates  in  forgetting  the 
script  letters,  and  the  patient  scribbles  all  over  the  paper. 

The  letters  may  be  pathologically  changed,  either  by  being 


^  Erlenmeyer,  Die  Schrift.     Stuttgart,  1879. 


82  General  Symptomatology. 

irregular  and  atactic  (approximation  of  the  writing  of  the  adult 
to  that  of  the  child  just  learning  to  write,  excessive  let- 
ters, the  straight  line  is  not  observed,  hair  strokes  are  zigzag- 
shaped;  or  there  may  exist  trembling,  as  in  paresis,  alcoholism, 
and  senile  dementia). 

[Mirror  writing  is  the  act  of  writing  a  word  from  right  to 
left  or  in  the  direction  of  the  left  hand,  in  contradistinction  to 
the  usual  method  from  left  to  right.  It  is  called  mirror  writing 
because  it  can  be  easily  read  in  a  mirror,  where  the  reflection 
appears  as  in  ordinary  writing. 

According  to  Savage,^  mirror  writing  is  met  with  in  some 
forms  of  mental  weakness,  and  in  conditions  of  mental  disorder 
allied  to  the  hysterical;  occurring  in  imbeciles,  paretics,  espe- 
cially in  apoplectic  psychoses,  also  in  cases  of  moral  perversion, 
where  it  may  be  only  temporar}',  and  l^eing  observed  more  com- 
monl}^  among  women  than  among  men,  and  most  easily  acquired 
in  highly  nervous  people.  Mills  in  189-i-  reported  a  case  in  a 
boy  15  years  old,  who  would  he  classed  with  the  highest  grade  of 
imbeciles.  Ireland  gives  the  details  of  several  interesting  cases 
(quoted  by  Mills),  one  a  paral}'tic  imbecile  girl,  between  11  and 
12  years  old  when  studied;  another  was  a  genetous  imbecile  girl 
of  14;  another,  a  congenital  imbecile  of  13;  another,  a  boy  of 
moderate  intelligence  of  13.  He  also  mentions  two  left-handed 
idiot  boys  who  formed  pothooks  from  right  to  left. 

The  left-handed  show  a  ph3'siological  tendency  to  mirror 
writing.  Of  a  class  of  six  boys  and  girls  who  tried  to  write  their 
names  with  their  left  hands,  two  girls  and  three  boys  wrote  in 
mirror  writing,  and  all  of  these  were  found  to  be  left-handed. 
Out  of  another  set  of  children,  six  were  left-handed,  and  three 
of  these  were  mirror  writers. — Ed.]^ 

There  are  also  patients  who  pronounce  words  in  the  same 
manner  {mirror  speech),  that  is,  they  use  the  last  letter  first  and 
the  others  follow  and  place  the  first  last;  instead  of  "mother," 
they  say  "rehtom."  (This  mirror  speech  is  sometimes  used  by 
school  children.     Imbecile  children,  who  are  often  left-handed. 


^  Tuke's  Dictionaiy  Psychological  Medicine. 
-Journal  of  Nervous  and  Mental  Disease,  1894,  p.  88. 
^American  Journal  of  Insanity,  vol.  LV.,  No.  1. 


The  Expression.  83 


also  frequently  show  a  tendency  to  the  reversion  in  spelling  and 
pronouncing  words). 

4.  The  expression  of  the  countenance  in  the  insane  may 
be: — 

(a)  A  maniacal  one,  with  lively  play  of  muscles,  glistening 
eyes,  and  a  startling  glance  expressed  by  the  constant  movements 
of  the  eye. 

Here,  the  play  of  the  zygomatic  muscles,  the  pyramidales 
nasi,  and  the  orbiculares  palpebrarum,  which  denote  internal 
excitement  with  the  feeling  of  pleasure,  are  especially  vivid. 

(&)  A  depressive  one.  The  muscles  of  the  face  are  in  a 
hypertonic  condition.     The  frontalis  is  contracted,  hence  the 

a^i  ^orJoQ 

Mirror- writing.     (Collins.) 

forehead  is  drawn  into  horizontal  furrows,  to  which  perpendic- 
ular clefts  are  joined  by  the  contraction  of  the  corrugators  with 
the  drawing  together  of  the  proximal  ends  of  the  eyebrows.  The 
eye  appears  dull  and  dim,  because  the  clefts  of  the  eyelids  are 
narrowed  by  the  contraction  of  the  orbiculares  palpebrarum  and 
the  moisture  of  the  tears  is  wanting.  The  mouth  is  closed  by 
the  contraction  of  the  orbicularis  oris,  very  often  the  comers  of 
the  mouth  are  aiso  drawn  down. 

(c)  An  observing  one.  The  expression  of  the  face  is  that 
of  a  man  who  waits  for  something  with  a  certain  degree  of  ten- 
sion, the  ears  are  "pointed,"  the  eyes  fixed,  especially  in  the 
hallucinated,  who  observe  their  illusions  or  hallucinations. 

(d)  An  idiotic  one.  The  muscles  of  the  face  are  hypotonic, 
the  eye  is  vacant,  the  mouth  half  opened,  saliva  flows  out,  and 
sometimes  with  this  there  is  a  pretense  at  smiling.  (State  of 
dementia ;  see  also  h}^otonic  stupor) . 


84  General  Symptomatology. 

{e)    A  peculiar  expression  of  the  face  has  been  mentioned 
above  in  the  discussion  of  l-atatonic  stupor. 


X.  THE  PATHOLOGICAL  DISTURBANCES  IN  THE 
CONDITION  OF  THE  BODY. 

Stigmata  of  Degeneration. 

[To  classify  the  various  stigmata  of  the  degenerate,  we  may 
divide  the  life-history  of  the  individual  into  three  epochs : — 

1.  The  Pre-Katal  Epoch,  embracing  teratological  evidence 
of  degenerac}'. 

2.  Post-Xatal  Epoch,  where  the  evidence  is  purely  objective 
or  physical  and  functional. 

3.  The  Post-Developmental  Epoch,  where  the  evidence  is 
mainly  subjective  or  psychical. 

I.  Pre-Natal  Epoch. 

The  writer  is  at  present  unprepared  to  state  positively  in 
how  far  teratology  is  to  be  considered  as  evidence  of  degeneracy, 
but  would  go  on  record  as  stating  that  the  causes  underlying 
degeneration  from  a  physical  and  psychical  standpoint  are  in 
the  majority  of  cases  identical  with  those  upon  which  the  science 
of  teratology  rests. 

II.  Post-Xatal  Epoch. 

Physical  Stigmata.  "We  may  divide  the  physical  stigmata 
into  two  subdivisions : — 

A.  Morphological  deviations  from  the  normal. 

1.  Deviations  of  the  general  proportions  of  the  body. 

2,  Peculiar  forms  of  special  parts. 

B.  Functional  deviations  from  the  normal. 

1.  Lack  of  functional  activity  of  the  general  organs 
of  the  body. 

2.  Lack  of  functional  activity  of  the  special  organs. 

3.  Developmental    irregularities,    including    habits. — 
Ed.] 


stigmata  of  Degeneration.  85 


1.  The  Cranmm  and  the  So-called  Signs  of  Physical 
Degeneration. 

The  cranial  measurenients  of  the  living  to  be  taken  are: — ^ 

(a)  The  horizontal  circumference,  measured  with  the  steel 
tape  measure,  which  is  placed  directly  over  the  arch  of  the  eye- 
brows and  over  the  most  prominent  point  of  the  occiput. 
Twenty  millimeters  in  males  and  30  millimeters  in  females  are 
to  be  deducted  for  comparison  with  the  naked  skull. 

In  men  521  millimeters,  in  women  503  millimeters,  is  as- 
sumed as  the  average  horizontal  circumference  of  the  naked 
skull. 

Eegular  crania  of  over  550  millimeters  are  called  kepha- 
lones  (to  be  distinguished  from  the  crania  abnormally  en- 
larged by  hyperostosis  or  hydrocephalus). 

If  the  horizontal  circumference  falls  below  -iQ'Z  millimeters 
the  condition  is  to  be  denominated  microcephalus  (nannoceph- 
alus). 

(&)  The  greatest  length  (L),  measured  with  the  calipers, 
without  reference  to  the  horizontal  plane,  from  the  middle  of 
the  arcus  superciliares  to  the  most  prominent  point  of  the  occi- 
put. This  should  be  (after  deducting  30  to  30  millimeters  for 
the  scalp)  18.3  centimeters  for  men  and  17.8  centimeters  for 
women. 

(c)  The  greatest  breadth  (B),  measured  with  the  sliding- 
circle,  perpendicularly  to  the  sagittal  plane,  excluding  the  vertex 
and  the  posterior  temporal  fossa. 

The  points  of  measurement  must  lie  in  a  horizontal  plane. 

After  deducting  5  millimeters,  the  average  in  men  is  15.0 
centimeters;  in  women,  14.0  centimeters. 

[The  normal  head,  so-called,  is  judged  by  the  ratio  which 
the  length  of  the  head  bears  to  the  breadth,  when  viewed  from 
above.  The  antero-posterior  is  to  the  bi-parietal  diameter  as 
100  is  to  X,  is  the  formula  for  determining  the  cephalic  index 
(^V  All  length-breadth  indices  below  78  are  considered  doli- 
chocephalic; 78  to  80,  mesocephalic ;  above  80,  brachycephalic ; 
80  to  85  and  over,  hyperhrachycephalic.     All  indices  between 


"•Eieger.     Eine  exacte  Methode  der  Kraniographie.  Jena,  1885. 


86 


General  Symptomatology. 


70  and  90  may  be  considered  pli3-siological  variations.     (Peter- 
son.) 

The  physiological  variations  dependent  upon  age,  and  the 
artificial  deformities  as  practiced  by  the  Polynesians  and  the 


Degrees  of  Cba^io-facial  Angle.     Prognathism. 


Fig.  1. — Facial  angle  of  man 
.A 


Fig.  2. — Type  of  progna- 
thous European. 


Fig.  3. — Facial  angle  of  the 
chimpansee.     A,  B,  Facial 
line;    B,  C,   horizon- 
tal line. 


Fig.  4. — Prognathous  skull 

of    a    criminal    Italian 

woman.     ( Lombr  oso ) . 


Indians  of  Xorth  and  South  America,  must  not  be  included 
among  the  irregular  types. 

The  dolichocephalic  or  long-headed  races  are  the  English, 
Irish,  Scandinavians,  and  Xegroes,  with  an  index- of  73;  Arabs, 
T4;  Chinese,  76.  The  brachycephalic  or  broad-headed  are  the 
Germans,  Eussians,  and  Turks,  with  an  index  of  81;  while  the 


Stiginidii  of  Dcycncnition. 


87 


mesocepiialic  or  mediums  are  the  American  Indians,  Hollanders, 
and  Parisians,  with  an  index  of  79. 

(d).  Facial  Angle.  A  line  drawn  from  the  anterior  ex- 
tremity of  the  premaxilla  to  the  anterior  extremity  of  the  basi- 
cranial  axis  may  be  taken  to  represent  the  facial  axis,  and.  the 
angle  included  between  these  two  is  the  cranio-facial  angle.  It 
varies  with  the  extent  to  which  the  face  lies  in  front  of  or  below 
the  anterior  end  of  the  cranium,  from  less  than  90°  to  120°. 


Fig.^. — A  peasant  with  sanguinary  instincts.    Alveolar  subnasal 
prognathism. — Schack} 


(Huxley.)  Francotte  gives  the  average  for  European  races  as 
62°  to  80°. 

We  designate  as  prognathous,  the  facial  cranium  whose 
angle  reaches  to  82°;  as  mesognathous,  where  the  angle  varies 
from  83°  to  90°  ;  and  as  hypcrorthognathous,  in  which  it  reaches 
90°  or  over. 

Every  normal  face  presents  this  sub-nasal  prognathism,  but 
when  extreme  prognathism  or  orthognathism  is  met  with  the 


1887. 


^  La  physionomie  chez  I'homme  et  chez  les  animaiix,  pag.  365.    Paris, 


General  Symptomatology. 


condition  is  pathological.  Excessive  prognathism  is  found 
among  criminals  and  microcephalics.  Lombroso,  in  an  exam- 
ination of  40  criminals,  found  only  three  whose  facial  angle  was 
80°  to  81°,  while  in  the  other  37  it  ranged  from  68°  to  74°. 

The  face  as  a  whole  has  been  regarded  for  centuries  as  por- 
traying the  underlying  deep-seated  nature  of  the  individual,  and 
in  every-day  life  is  the  mirror  which  reveals  the  sagacity,  honesty, 
and  good-will  of  its  bearer.  Its  expressions  have  been  as  care- 
fully studied  as  have  been  the  emotions  which  give  rise  to  them, 
but  as  yet  no  scientific  study  has  been  made  of  them. 

As  marks  of  degeneration  we  do  consider  asymmetries  in 
the  two  sides  of  the  face ;  unequal  innervation  of  the  facial  mus- 
cles of  the  two  sides;  squints  and  tics  of  the  facial  muscles;  a 
depression  over  the  glabella,  as  observed  in  epileptics,  due  to 
over-action  of  the  corrugators;  the  Lemurian  hypophysis  or  ab- 
normal development  of  the  masticatory  muscles,  as  described  by 
Albrecht.  Not  to  be  included  in  these  anomalies  is  the  affection 
known  as  hemiatrophia  facialis,  or  atrophy  of  one-half  of  the 
face,  right  or  left  side,  due  to  some  lesion,  probably  of  the  trige- 
minus. 

Although  the  skull  has  been  the  subject  of  anthropological 
research  for  many  years,  each  investigator  endeavoring  to  formu- 
late certain  laws  which  shall  be  useful  in  distinguishing  racial 
characteristics  or  in  aiding  the  criminologist  and  alienist  in  de- 
ciding upon  the  degree  of  responsibility  or  irresponsibility  of 
the  indicted  or  suspected  transgressor,  yet  their  labors  have  not 
borne  the  desired  results,  as  cranial  deformities  and  dissimilari- 
ties are  present  in  races,  tribes,  and  even  in  members  of  the  same 
families. 

Deviations  from,  the  Normal  Skull. 

Virchow  has  given  us  a  very  complete  classification  of  the 
deformities  of  the  skull,  based  upon  the  observation  that  prema- 
ture SATiostosis  of  a  suture  produces  a  shortness  of  the  diameter, 
perpendicular  on  the  direction  of  the  obliterated  suture;  the  bone 
stops  growing  prematurely  where  the  synostosis  has  occurred, 
whereas  the  non-affected  borders  continue  growing.  Virchow's 
classification  is  as  follows: — 


stigmata  of  Degeneration.  89 


1.   Simple  inacroccjdialus. 

1.  llydr()ce])lialus. 

2.  Kephaloncs  without  li^-droeephalus  (or  simply  enlarge- 
ment of  the  skull). 

II.  Simple  microcephalus. 

The  average  circumference  of  an  adult  skull,  male,  is  52 
centimeters,  female  50  centimeters,  the  phj^siological  variations 
ranging  from  48.5  centimeters  to  57.4  centimeters. 

The  macrocephalic  skull,  which  in  the  large  majority  of 
cases  is  due  to  hydrocephalus,  may  be  the  result  of  a  tubercular 
meningitis,  or  of  obstruction  of  the  ven^  Galeni,  or,  as  is  usually 
the  case,  of  foetal  development  and  often  hereditary. 

Microcephalus  is  due  to  early  ossification  of  the  sutures  and 
fontanelles  and  is  frequently  productive  of  idiocy,  epilepsy,  cre- 
tinism, and  other  degenerative  neuroses.  The  causes  of  early 
ossification  may  be  rachitis,  or  insufficient  nutrition  of  the  cranial 
bones  from  early  obliteration  of  the  nutrient  vessels,  or  lack  of 
development  of  the  bony  tissue  from  inhibition  due  to  inflam- 
matory changes  in  the  sutures. 

True  microcephalus  demands  a  bilateral  and  symmetrical 
lack  of  development  of  the  entire  skull.  If  the  vertex  of  the 
skull  is  undeveloped  whilst  the  basal  bones  attain  their  proper 
size,  the  Aztec  type  of  microcephalus  results.  Another  rather 
rare  form  of  microcephalus  results  when  the  small  skull  with 
thick  bones,  and  synostosis  at  the  vertex,  has  the  basal  bones  re- 
maining cartilaginous;  the  petrous  bone  and  the  ethmoid  are 
larger  than  normal,  while  the  cerebellar  fossa  is  unusually  large ; 
the  cerebellum,  pons,  and  spinal  cord  develop  to  the  detriment  of 
the  cerebrum,  which  remains  illy  developed.  Griesenger  com- 
pares these  idiots  to  birds,  with  their  long-pointed  and  beaked 
nose  and  small,  low,  and  short  heads. 

The  degenerative  tendency  of  microcephalics  is  well  illus- 
trated in  a  case  published  in  the  Journal  of  Nervons  and  Mental 
Disease,  July,  1892.^  The  head  measurements  of  this  woman, 
possessing  limited  intelligence,  age  27  years,  4  feet  11  inches  in 
height,  and  of  110  pounds  weight,  were  as  follows:  Circumfer- 
ence, 48  centimeters ;  oecipito-f rontal  diameter,  14  centimeters ; 
bitemporal   diameter,   13   centimeters;   biparietal   diameter,    13 

^  Krauss,  Wm.  C. 


90  General  Symplomatology. 

centimeters;  occipito-mental  diameter,  20^2  centimeters;  sub- 
occipito  bregmatic  diameter^  16  centimeters,  ^tarried  in  1884, 
she  had  given  birth  to  five  children,  all  of  whom  were  micro- 
cephalic at  birth.  During  dentition  three  of  them  became  ma- 
crocephalic,  undoubtedly  hydrocephalic,  dying  of  meningitis, 
and  two  died  of  convulsions,  the  head  remaining  microcephalic. 
III.  Dolichocephalus. 

1.  Upper  middle  synostosis.  Simple  dolichocephalus  (or 
long  head),  the  result  of  s3Tiostosis  of  the  sagittal  suture. 
Sjjhenocephalus  (or  wedge-shaped  head)  is'  due  to  sjTiosto&is  of 
the  sagittal  suture,  with  compensatory  growth  in  the  region  of 
the  large  fontanelle. 

2.  Inferior  lateral  synostosis.  Leptocephalus  (or  narrow 
head),  the  result  of  s}Tiostosis  of  the  frontal  and  s^jhenoid  bones. 
Xlinocephalus,  s^Tiostosis  of  the  parietal  and  sphenoid  bones. 

IT.  Brachycephalus. 

1.  Posterior  synostosis.  Paracejjhalus  (or  thick-skulled), 
the  result  of  synostosis  of  the  parietal  bones  with  the  occipital 
bones.  Oxycephalus  (or  steeple  head),  produced  by  synostosis 
of  the  parietal  bones  with  the  occipital  and  temporal  bones,  with 
compensatory  growth  of  the  region  of  the  anterior  fontanelle. 

2.  Tpper  anterior  and  lateral  synostosis.  Platycephalus 
(or  flat  head),  produced  by  extensive  synostosis  of  the  frontal 
and  parietal  bones.  Trochocephalus  (or  round  head),  the  result 
of  partial  synostosis  of  the  frontal  and  parietal  bones  in  the 
middle  of  the  half  of  the  coronal  suture.  Plagiocephalus 
(twisted  head),  or  oblique  deformity  of  the  head,  due  to  the 
imilateral  synostosis  of  "the  frontal  and  parietal  bones. 

3.  Inferior  median  synostosis.  Simple  brachycephalus  (or 
broad  head),  the  result  of  early  synostosis  of  the  basal  and 
sphenoid  bones. 

Besides  these  cranial  deformities  there  is  still  another  quite 
common  type  recognized  by  many  observers  as  the  trigonoceph- 
alus  (or  triangle-shaped  head),  caused  by  the  premature  union 
of  the  frontal  suture.  Characteristic  of  this  deformity  is  the 
very  narrow  forehead  corresponding  to  the  vertex  of  a  triangle, 
while  the  diverginsf  sides  of  the  cranium,  terminating  in  a  wide, 
flat  occiput,  correspond  to  the  base  of  the  triangle.  An  interest- 
ing example  of  this  kind  came  imder  my  notice  about  two  years 


stigmata  of  Degeneration.  91 

ago  in  a  paranoiac,  who  shot  down  the  center  of  a  supposed  con- 
spiracy which,  as  he  thought,  was  directed  against  his  mother. 
Besides  other  marks  of  degeneracy,  the  cranium  possessed  the 
well-marked  characteristics  of  trigonocephalus.^ 

In  addition  to  these  well-known  types  of  cranial  deformity 
there  are  other  stigmata  which  occur  occasionally  in  the  crania 
of  degenerates,  consisting  in  abnormally  high  or  low  develop- 
ment of  certain  arcs  or  diameters,  prominent  among  these  being 
the  empirical  greatest  height  of  the  head  or  the  distance  between 
the  basion  and  vertex  of  the  skull,  the  bi-frontal  arc,  and  the 
bi-parietal  arc. 

The  proportion  of  the  length  of  the  cerebral  chamber  to 
the  basi-cranial  axis  (as  100)  may  rise  to  270  in  the  higher  and 
sink  to  230  in  the  lower  races,  (Huxley.-)  Expressed  in  cen- 
timeters, this  height  or  basi-cranial  axis  averages  13.3  in  men, 
12.3  in  women,  and  the  physiological  variation  is  from  11.5  to 
15  centimeters. 

The  naso-bregmatic  or  frontal  arc,  or  the  line  from  the 
root  of  the  nose  to  the  bregma,  expressing  a  high,  low,  or 
receding  forehead,  averages  12.5  centimeters  in  men,  12  in 
women,  with  a  physiological  variation  between  10.9  and  14.9 
centimeters. 

The  bregmato-lambdoid  or  parietal  arc,  corresponding  to 
the  length  of  the  sagittal  suture,  averages  12.5  centimeters  in 
men,  12  in  women,  with  a  physiological  variation  between  9.1 
and  14.4  centimeters.     (Peterson.) 

Minimal  measurements  of  the  frontal  arc  are  oftener  found 
in  the  insane  and  criminals;  the  parietal  arc  is  also  said  to  be 
often  shorter  in  the  insane  defective  and  delinquent  classes  and 
in  epileptics.  In  these  classes,  however,  maximal  excesses  also 
often  occur.  (Dana.^)  Of  127  measurements  made  by  Zucker- 
Kundler  upon  insane  subjects,  103  showed  a  typical  variation, 
or  more  than  81  per  cent.  Wilson,*  from  measurements  of  the 
heads  of  464  criminals,  finds  that  the  anterior  portions  are  poorly 
developed  and  that  the  cranial  deficiency  is  associated  with  real 


"■  American  Journal  of  Insanity,  January,  1895. 
^  Anatomy  of  Vertebrate  Animals. 
^Text-book,  JS'ervous  Diseases. 
*  Berry,  J.  J.,  Medical  Age,  Feruary  10,  1896. 


92  General  Symptomatology. 

ph3'sical  deterioration,  i'urcy  per  cent,  are  invalids,  and  a  still 
larger  proportion  of  these  are  professional  thieves.  Asymmetry,- 
though  olten  existing  in  normal  subjects,  is  much  more  constant 
and  pronounced  in  the  criminal  and  is  frequently  a  character- 
istic mark  of  his  family  and  descendants. 

Skulls  that  are  below  the  normal  type  in  volume  belong  to 
abnormal  individuals,  especially  the  insane  and  criminals.  A 
marked  deficiency  in  any  portion  of  the  skull  leads  to  the  con- 
clusion that  the  part  of  the  brain  subjacent  to  it  is  imperfectly 
developed.  Yoisin  says  that  the  proper  exercise  of  the  intel- 
lectual faculties  is  impossible  with  a  head  whose  circumference 
measures  from  28  to  33  centimeters  or  less. 

Since  lack  of  symmetry  exists  between  the  two  sides  of  the 
body,  so,  too,  in  the  skull  of  normally  developed  individuals  we 
find  variations  in  the  size  of  the  two  halves  of  the  cranium.  A< 
a  rule  the  left  side  of  the  head  presides  over  the  right  side  of 
the  body ;  and  as  the  right  side  of  the  body  is  usually  more  fully 
developed  than  the  left,  and  muscular  strength  is  generally  in 
excess  on  that  side,  it  would  seem  to  follow  that  the  left  side  of 
the  head  should  present  the  largest  contour.^  This  proves  to 
be  the  case,  the  left  side  being  larger  than  the  right  in  the  pro- 
portion of  three  to  one.  As  BroAvn-Sequard  has  demonstrated, 
the  left  lobe  of  the  brain  comes  into  greater  use  in  its  control 
of  the  right  side  of  the  body  than  does  the  right  lobe  in  its  con- 
trol of  the  left  side.  Unequal  muscular  and  cerebral  develop- 
ment bear  a  relation  also. 

From  a  careful  study  and  analysis  of  the  cranial  deformi- 
ties and  aberrations,  it  is  generally  admitted : — 

1.  That  no  special  type  or  types  of  cranial  deformity  or 
irregularity  have  as  yet  been  found  pathognomonic  of  any  class 
or  classes  of  degenerates. 

2.  That  wide  variations  do  occur  in  the  normally  developed 
and  well-balanced  individuals. 

3.  But  it  must  also  be  admitted  that  along  with  other  phy- 
sical, mental,  and  moral  stigmata,  these  cranial  variations  are 
significant  and  important  and  are  of  the  greatest  value  to  the 
anthropologist,   criminologist,   and   alienist. 


'■Merz,  C.  H.,  Medical  Age.  December  26,  1891. 


Stigmata  of  Degeneration.  93 


The  Ear. 

The  ear,  perhaps  on  account  of  its  prominence  and  extreme 
liability  to  deformity  and  irregularity  because  of  its  cartilaginous 
structure,  has  been  the  subject  of  many  papers  and  monographs 
by  alienists  and  anatomists  and  plays  an  important  part  in  the 
Bertillon  system  of  identifying  criminals. 

The  perfect  ear,  which  is  rarely  met  with,  should  be  about 
twice  as  long  as  broad,  and  should  be  attached  to  the  head  almost 
straight  or  slightly  inclined  backwards,  and  should  touch  the 
head  with  the  back  of  its  upper  point.  Mothers  and  nurses  are 
to  blame  for  many  of  the  irregular  positions  of  the  ears  of  chil- 
dren, but  nature  only  for  the  deformities  and  irregular  implanta- 
tions which  are  so  frequently  met  with  in  the  degenerate  classes. 

Binder  gives  in  his  monograph  the  following  analysis  of 
Morel's  ear  (the  ear  of  the  degenerate)  : — 

I.  Anomalies  in  the  configuration  of  the  ear  as  a  whole. 

1.  The  variations  in  size. 

2.  The  implantation. 

3.  Abnormalities  in  the  general  configuration. 

4.  Inequality  of  the  two  ears. 

II.  Anomalies  in  the  architecture  and  form  of  the  parts 
composing  the  ear. 

1.  The  lobule  may  be  excessively  long  or  adherent  or  absent, 
Coloboma  lobuli  hypertrichosis. 

2.  Anomalies  of  the  helix. 

3.  Anamolies  of  the  anthelix. 

4.  Anomalies  of  the  crura  furcata  and  fossa  ovalis. 

5.  Anomalies  of  the  tragus  and  antitragus. 

6.  Anomalies  of  the  concha  and  fossa  cymbse. 

7.  Anomalies  of  the  fossa  scaphoidea. 

From  the  analysis  of  these  points  he  arrives  at  the  following 
types  of  ears: — 

1.  The  defectively  implanted  ear. 

2.  Excessively  large  ears. 

3.  Excessively  small  ears. 

4.  The  excessively  folded  ear. 

5.  The  irregularly  shaped  ear  (especially  the  ear  with  ab- 
normally small  upper  portion). 

6.  Ears  varying  in  breadth. 


94  General  Symptomatology. 

T.  Blainville's  ears  (asymmetry  of  the  two  earsj. 

8.  Ear  without  lobule. 

9.  Ear  with  adherent  lobule. 

10.  Stahl's  ear  (1).  The  helix  is  very  broad  in  the  trans- 
verse portion  and  partly  covering  the  fossa  ovalis.  The  lower 
part  of  the  helii  is  absent. 

11.  Darwin's  ear  (with  marked  tubercle  at  the  beginning  of 
the  descending  part  of  the  helix). 

13.  Wildermuth's  ear   (anthelix  prominent), 

13.  The  ear  without  anthelix  and  crura  furcata. 

14.  Stahl's  ear  (2).  Wide  bifurcation  of  crura;  multiple 
bifurcation,  especially  of  the  upper  cms, 

15.  Wildermuth's  Aztec's  ear.  Lobide  absent.  The  upper 
cms  of  the  anthelix  goes  over  into  the  flat  helix  without  any 
demarcation:  the  lower  cms  is  very  deep  and  apparently  absent, 
the  upper  cms  thus  forming  the  margin  of  the  concha. 

16.  Stahl's  ear  (3).  Only  the  cms  anterius  present;  the 
cms  superius  merely  a  node  of  cartilage.  The  concha  apparently 
divided  by  an  additional  process  starting  from  the  antitragus. 

IT.  The  ear  with  double  helix,  the  cms  superius  not  even 
indicated :  rare. 

18.  Concha  too  large  or  too  small. 

19.  The  ear  with  a  scaphoid  fossa  extending  into  the  lobule, 

20.  MoreFs  ear;  flat  and  broad  in  the  upper  parts.  Cms 
superius  broad,  flat ;  scapha  broad  and  shallow. 

21.  Malformations  of  cartilage,  excluding  the  one  caused 
by  othaBmatoma. 

22.  Atypical  malformation,  coloboma. 

Tlie  Eye. 

The  eye,  on  account  of  its  complex  development,  is  perhaps 
prone  to  more  variations  and  disturbances  during  its  growth 
than  any  other  organ  in  the  body,  and  the  evil  effects  of  degen- 
eracy are  surprisingly  shown  in  the  formation  of  its  various 
parts. 

Taken  a=  a  whole  the  degenerate  eye  may  be  too  large:  (1) 
Megalophthalmus :  or  too  small  (2)  Micropthalmus.  The  for- 
mer condition  must  not  be  confounded  with  the  exophthalmus 
so  frequently  met  with  in  Basedow's  disease,  which  is  of  fune- 


Stigmata  of  Degeneration. 


95 


Types  of  Cranial  DEroKiiixY. 


Microcephalus. 


Normal. 


Macrocephalus. 


Dolichocephalus. 


Brachycephalus. 


Leptocephalus. 


Trigonocephalus.  Spienoeeplialus.  Oxycephalus. 


Platycephalui 


Trochocephalus.  Plagiocephalus. 


96  General  Symptomatology. 


tional  nature,  due  probably  to  some  disturbance  of  the  sympa- 
thetic nervous  system. 

Microphthalmus  is  more  often  observed  than  macrophthal- 
mus,  and  its  presence  in  a  member  of  a  family  should  lead  to  a 
careful  examination  of  the  family,  with  a  view  of  detecting  other 
stigmata  of  degeneration.  A  case  recently  came  under  my  ob- 
servation in  a  lad  twelve  years  of  age,  whose  sister  I  was  called 
to  see  in  consultation.  The  sister  was  found  to  have  Friedreich's 
ataxia,  a  family  disease.  Xot  detecting  this  affection  in  any  of 
the  other  members,  I  looked  them  over  carefully,  with  the  follow- 
ing result:  In  the  family  of  three  microphthalmus  of  the  right 
eye  was  found  in  the  brother  referred  to,  and  in  the  sister  was 
found  a  Gothic  palate,  twisted  uvula,  and  an  irregular  formation 
of  the  maxilla  and  mandible.  One  cousin  was  in  the  State  hos- 
pital, and  another  was  eccentric  in  regard  to  dress  and  society, 
and  another  had  been  insane.  The  father  of  the  lad  had  been 
an  alcoholist,  and  the  mother  died  of  consumption  soon  after  the 
birth  of  the  sister  with  Friedreich's  ataxia.  No  information 
could  be  gleaned  concerning  the  grandparents. 

Other  stigmata  of  the  various  parts  of  the  visual  apparatus 
are  as  follows : — 

Lids.  3.  Microblepharon.  4.  Symblepharon.  5.  Coloboma 
palpebrse.     6.  Epicanthus.     7.  Congenital  ptosis. 

Cornea.  8.  Dermoid  adhesions  on  the  cornea,  especially 
small  tufts  of  hair. 

7m.  9.  Coloboma  iridis,  partial  or  complete.  10.  Aniridia. 
11.  Polykoria.  12.  Membrana  pupillaris  perseverans.  13.  Co- 
rectopia.  l-l.  Asymmetrical  coloration  of  the  iris  in  whole  or  in 
part.     15.  Oval  or  eccentric  pupil. 

Interior  of  the  Orhit.  16.  Coloboma  choroidsea,  congenital. 
17.  Coloboma  lentis,  congenital.  18.  Staphyloma  posticum 
scarpnl.  19.  Arteria  hyaloidea  persistens.  20.  Persistent  nerve 
fibers  of  tlie  retina.     21.  Eetinitis  pigmentosa. 

Muscular  Defects.  22.  Nystagmus,  congenital.  23.  Strabis- 
mus, congenital. 

Physiological  Variations.  2-1.  Hemeralopia.  25,  Daltonism. 
26.  Abnormalities  of  the  visual  iield. 

Visual  defects  are  common  among  the  degenerate  classes, 
and  though  sometimes  acquired  are  generally  congenital.     Of  83 


stigmata  of  Degeneration.  97 


criminals  cxaniincd  by  Ellis,  G7  per  cent,  were  found  to  have 
optical  lesions;  and  out  of  40  of  the  instinctive  variety,  72  per 
cent,  were  thus  affected.  An  examination  of  101  children  in  a 
reformatory  institution  by  Van  Fleet  disclosed  the  fact  that  67 
per  cent,  had  defective  vision. 

The  visual  field  has  been  thoroughly  studied  by  the  School 
of  the  Salpetriere,  Oppenheim  and  Siemerling,  and  recently  by 
Ottolenghi,  who  states  that  the  measurements  of  the  visual  field 
may  be  of  great  value  under  many  circumstances  in  legal  medi- 
cine : — 

1.  By  the  study  of  the  sensibility  in  general  and  the  psychic 
examination  of  the  degenerates,  as  is  shown  by  the  investigations 
made  of  cretins  and  deaf-mutes. 

2.  By  bringing  out  features  that  may  be  diagnostic  of  epi- 
lepsy and  congenital  criminality. 

3.  By  furnishing  symptomatic  data  not  pathognomonic, 
but  frequent  in  neuroses  and  traumatic  epilepsy,  and  for  testing 
the  sincerity  in  certain  mental  states  and  unmasking  skilled 
simulation. 

Hard  Palate. 

The  deformities  of  the  hard  palate  have  been  carefully 
studied  by  Peterson,  whose  observations  in  this  direction  ex- 
tended over  a  period  of  eleven  years,  and  comprised  examinations 
on  upwards  of  one  thousand  persons  (100  criminals,  600  idiots, 
and  500  neuropaths  of  other  kinds).  On  account  of  the  fre- 
quent mention  of  the  Gothic  palate,  he  had  adopted  an  architec- 
tural nomenclature  in  the  following  classification  which  he  of- 
fered : — 

Pathological  Palate. — "(ft)  Palate  with  Gothic  arch;  (&) 
palate  with  horseshoe  arch;  (c)  the  dome-shaped  palate;  [d) 
the  flat-roofed  palate;  (e)  the  hip-roofed  palate;  (/)  the  asym- 
metrical palate,  and  {g)  the  torus  palatinus.  The  seven  varieties 
are  to  be  looked  upon  merely  as  types.  Each  type  presents  varia- 
tions and  combinations  with  other  forms.  Among  the  flat- 
roofed  palates  would  be  included  all  such  as  are  nearly  horizontal 
in  outline,  as  well  as  those  with  inclined  roof  sides  but  flattened 
tables.  In  the  hip-roofed  palate  there  is  a  marked  pitch  of  the 
palate  roof  in  front  and  behind.     It  is  usual  to  find  asymmetry 

7 


98  General  Symptomaiologij. 

of  the  face  and  skull  in  cases  with  asymmetrical  palate.  The 
torus  jjalatinus  (Latin  torus,  swelling)  was  first  mentioned  by 
Chassignac  as  a  medio-palatine  exostosis.  It  is  a  j)rojecting 
ridge  or  swelling  along  the  palatine  suture,  sometimes  in  its 
whole  length.  It  is  always  congenital,  and  varies  considerably 
in  both  shape  and  size.  But  two  or  three  cleft  palates  were  found 
among  the  many  idiots  examined,  and  as  a  number  of  such 
palates  had  been  found  in  subjects  who  were  far  from  being 
degenerated,  it  was  not  thought  proper  to  include  the  cleft  palate 
among  the  well-marked  stigmata  of  degeneration.'^ 

The  Teeth. 

The  abnormalities  of  the  teeth  and  of  dentition  observable 
among  the  degenerates  are  briefly  as  follows: — 

1.  The  notched  teeth  of  congenital  S3^hilis  or  Hutchinson's 
teeth,  particularlv  well  marked  in  the  ujDper  central  incisors. 

2.  Persistence  of  the  milk  teeth,  especially  the  eye  teeth. 

3.  Abnormal  length  of  the  canine  teeth. 

4.  Abnormalities  in  the  shape  of  the  teeth. 

5.  Abnormalities  and  irregularities  in  the  position  of  the- 
teeth. 

6.  Eachitic  teeth. 

7.  The  teeth  of  extreme  prognathous  races  and  individuals 
are  much  larger  than  normal.  The  roots  of  the  premolars  and 
molars  are  more  distinct,  and  the  last  molar  not  so  small  rela- 
tively to  the  others.  This  is  observed  especially  in  the  lower 
races,  notably  the  Australians. 

The  Sl-m. 

Very  frequently  we  find  the  skin  of  the  degenerate  sallow 
or  pallid,  perhaps  leathery,  the  face  prematurely  wrinkled;  the 
persistence  of  the  branchial  clefts  and  pre-aural  sinuses  are  also 
of  some  importance,  and  the  presence  of  large  or  small  nasvi  or 
pigmented  areas.  The  presence  of  tattoo  marks  on  the  arms 
and  body  is  considered  one  of  the  predilections  of  this  class  of 
humanity.  Generally  the  beard  is  scanty,  while  the  growth  of 
hair  on  other  parts  of  the  body  is  abundant.  The  writer  remem- 
bers when  a  youth  the  siglit  of  a  man  in  bathing,  whose  entire 
body.  Avith  the  exception  of  the  upper  part  of  the  face,  palms  of 


Disturbances  of  iha  Scnsurlal  Apparatus.  99' 

hand,  and  soles  of  feet,  was  densely  covered  with  coarse  black 
hair.  The  ajipearance  of  Jo  Jo,  the  so-called  liussian  dog-faced 
bo}',  with  Barnuni's  circus,  many  will  remember  as  an  example 
of  this  kind. 

The  presence  of  congenital  spots  or  areas  of  baldness  on  an 
otherwise  hairy  head,  or  patches  of  gray  hair  appearing  very 
early  in  life;  the  absence  of  the  eyebrows  or  of  the  pnbic  hair; 
the  prolongation  of  the  eyebro\\s  on  the  two  sides  until  they 
meet  at  the  median  line;  the  scalp  covered  with  coarse,  heavy 
hair;  the  jDresence  of  hair}^  moles  on  various  jmrts  of  the  body; 
the  presence  of  long  tufts  of  black  hair,  especially  on  the  back 
or  abdomen,  are  all  more  or  less  signiJ&cant.  The  absence  of 
hair  over  the  chest  in  adult  males  is  constantly  being  referred  to 
by  Lanceraux  as  a  sign  of  physical  degeneracy,  indicative  gener- 
ally of  tuberculosis. — Ed.] 

In  the  genital  organs  appear  hypospadia,  epispadia,  cryptor- 
chidism; in  females,  very  large  clitoris,  hymen  in  the  form  of 
two  lips,  not  centrally  perforated,  oblique  closing  of  the  vagina. 

These  so-called  stigmata  of  degeneration  may  have  a  certain 
value  in  mental  diseases  only  when  they  are  not  sporadic,  but 
appear  in  gr.'at  number  in  the  same  person,  since  they  appear 
sporadically  ±ii  a  great  number  of  persons  mentall}^  sound,  and_ 
the  overestimation  of  the  significance  of  these  stigmata  leads 
one  to  see  the  "degenerate"  everywhere.  They  are  especially  fre- 
quent in  idiocy,  but  appear,  also,  in  the  most  various  states  ac- 
quired from  insanity,  and  become,  when  they  are  present  in  con- 
siderable number,  the  sign  of  a  consideralile  hereditary  taint. ^ 

2.  The  Disturbances  of  the  Peripheral  Sensorial 
Apparatus. 

Changes  in  the  peripheral  apparatus  of  smell  and  taste  have 
no  special  symptomatic  significance  in  mental  diseases.  Those 
of  audition  will  generally,  if  they  are  hereditary,  impair  the  men- 
tal development. 

The  eye  demands  a  special  discussion. 


'  For  a  full  discussion  of  the  Stifrmata  of  Degeneration  the  reader 
is  referred  to  Eugene  Talbot, "Degeneracy,  its  Causes,  Signs,  and  Results;" 
Frederick  Peterson,  American  Journal  of  Insanity.  July,  189.5;  William 
C.  Krauss,  American  Journal  of  Insanity,  vol.  LV.,  No.  1. 


100  General  Symptomatology. 

The  hope  that  the  ophthalmoscope  would  aid  us  in  the 
knowledge  of  functional  mental  diseases  has  not  as  yet  been 
realized. 

On  the  contrary,  it  shows  us  the  choked  disc  in  the  psychoses 
dependent  upon  focal  disease  of  the  brain,  the  atrophy  of  the 
oj)tic  nerve  in  paresis;  alcoholic  and  albuminuric  neuritis  optica 
in  alcoholic  or  uremic  psychoses;  sj'philitic  changes,  cysticercus, 
and  other  phenomena  which  may  be  of  importance  for  the  correct 
diagnosis  of  mental  disturbances. 

The  pupils  in  psychoses  ma}'  be  normal,  unequal,  much 
contracted  (myotic),  much  dilated  (mydriatic).  They  may  re- 
fuse to  react  to  light  and  accommodation,  or  they  may  simply 
remain  rigid  to  the  impression  of  light  while  they  contract  for 
accomodation. 

If  the  pupils  are  unequal,  one  must  first  observe  whether 
a  local  aSection  of  the  eye,  especially  a  different  refraction  of 
the  ej^es,  may  not  cause  the  difference.  If  this  is  not  the  case, 
such  a  difference  may  exist  from  childhood  contemporaneously 
with  an  unequal  development  of  the  cranium  on  both  sides 
(plagiocephalus).  Unequal  pupils  appear  transitorily  in  the 
most  varied  psychoses,  and  are  quite  often  found  in  the  state 
of  terminal  dementia.  Associated  with  other  paraMic  condi- 
tions, they  are  often  found  in  the  organic  mental  diseases,  espe- 
cially in  paresis.  The  s3'mptomatological  significance  of  an 
inequality  of  the  pupils  is  enhanced  when  the  degree  of  inequality 
clianges,  or  when  one,  then  the  other  pupil  becomes  more  dilated. 

]\Iyosis  is  often  the  accompaniment  of  senescence,  or  is  jiro- 
duced  by  medicines  (morphine,  chloral). 

Pin-jDoint  pupils  in  the  insane  indicate  some  organic 
psychosis,  in  most  cases  paresis. 

M}'driasis,  especially  the  jumping  kind,  that  is,  changing 
with  the  eye,  points  generally  to  a  developing  or  existing  paresis. 

Sometimes  dilated  pupils  are  observed  transitorily  in  epi- 
leptics or  in  states  of  confusion. 

The  disapjoearance  of  the  reaction  of  the  pupils  to  light  and 
accommodation  is  generally  regarded  as  a  symptom  of  a  severe 
organic  brain  or  spinal  cord  disease,  provided  there  is  no  peri- 
pheral or  nuclear  affection  of  the  oculomotorius  nerves. 

The  symptom  of  ArgyU-Rohertson   (loss  of  contraction  of 


Disturbances  of  Sensibility.  101 

the  pupil  when  light  strikes  it  directly,  while  the  pupil  contracts 
to  the  convergent  movement  of  the  eyeball,  is  found  very  fre- 
quently in  paresis;  then  in  luetic  psychoses,  especially  in  syph- 
ilitic basilar  meningitis;  furthermore,  occasionally  in  senile  de- 
mentia, in  alcoholic  polyneuritis,  and  in  sporadic  focal  diseases 
of  the  brain.  It  is  present  transitorily  in  epileptic,  but  only 
exceptionally  in  hystero-epileptic  seizures  (Westphal)  ;  likewise 
in  deep  drunkenness.  (Regarded  as  a  cardinal  symptom  of  loco- 
motor ataxia.) 

In  like  manner,  mydriasis,  which  results  in  the  majority  of 
cases  under  normal  conditions  through  irritation  of  the  sensory 
nerves,  is  often  unattainable  in  these  diseases.^ 

Sluggishness  in  the  reaction  of  the  pupils  frequently  takes 
place  transitorily  in  the  various  psychoses,  especially  in  the  epi- 
leptic psychoses.  i\.t  times  in  terminal  dementia,  exaggerated 
light  reaction  is  present. 

Sometimes  (especially  in  paresis)  an  inverted  type  of  the 
pupillary  reaction  to  light  is  found,  in  that  the  pupils  dilate  with 
the  ingress  of  light  {paradoxical  pupil  reaction).  On  closer  ob- 
servation it  generally  appears  that  a  contraction  follows  in  the 
first  moment,  which  quickly  gives  way  to  dilatation  on  account 
of  the  weakness  of  the  innervation. 

In  pupils  not  reacting  to  light,  on  attempting  to  close  the 
eyes  violently  by  the  musculi  orbiculares  oculi,  a  contraction  of 
the  pupils  may  appear  (Westphal,  Pilcz-). 

A  continuous  rapid  spasmodic  alteration  of  the  size  of  the 
pupil  of  one  or  both  eyes,  due  to  tremor  of  the  iris  (hippus),  is 
rare,  most  frequently  found  in  epileptic  and  hysteric  spasmodic 
states,  sometimes  in  traumatic  psychoses. 


3.  Disturbances  of  Sensibility. 

Headaches,  which  have  their  seat  now  in  the  anterior  part 
of  the  head,  then  in  the  posterior  part,  then  at  the  vertex,  are 
very  frequent  in  the  prodromal  and  initial  stages  of  the  functional 
psychoses,  and  in  hysteric  and  epileptic  psychoses;  they  are  in- 


'  Moeli.  Archiv  fiir  Psvehiatrie,  vol.  XIII,  p.  602. 

=  Neurologisches  Centriilblatt,  1899,  p.  161  and  248;   1900,  p.  43-4. 


102  General  Symptomatology. 

clined  to  clisaj)j)ear  during  the  height  of  the  disease,  only  to 
return  more  strongly  during  convalescence. 

In  the  same  Avay,  a  migraine  which  has  been  present  before 
the  advent  of  the  psychic  disease  usually  dejjarts  during  its 
cr.urse,  to  rcai)j)car  during  convalescence. 

lJy2)eresthesias  and  ncuralgil'orm  paius  are  ir<'<jnriit  in 
hypochondric  and  hysteric  psychoses;  but  il  is  Jiot  to  be  as- 
sumed that  determined  nerve  paths  have  definite  relations  to 
determined  delusions.  In  intoxication  psychoses  (alcohol,  dia- 
*  betes,  albuminuria),  the  various  hyperesthesias  and  neuralgiform 
pains  may  be  occasioned  by  a  neuritis. 

Ascertaining  whether  the  skin  is  7iy per  esthetic'  or  anesthetic 
in  a  given  area  is  often  impossible,  on  account  of  the  state  of 
consciousness  of  the  patient. 

Meiancholiacs  affirm,  e.g.,  in  convalescence,  that  they  felt 
ever}"  touch  and  every  prick  of  a  needle  while  the}"  seemed  en- 
tirely anesthetic  and  analgesic  at  the  time  of  examination.  The 
same  is  true  of  the  states  of  stupor.  In  hysteric  psychoses  anes- 
thesias of  the  most  varied  forms  and  of  the  most  different  dis- 
tribution are  very  frequent;  in  the  alcoholic  psychoses,  as  in  the 
most  varied  organic  psychoses,  disturbances  of  the  sensibility 
are  mostly  conditioned  by  neuritis,  medullary  affections,  and  dis- 
eases of  the  pons.     (See  also  paresis). 


4.  Disturbances  of  Motility. 

The  muscles  in  the  insane  may  be  in  a  hypertonic,  katatonic, 
or  in  a  hypotonic  state. 

Besides  stupor,  in  wliich  these  various  states  of  tension  have 
been  observed  and  described,  h}-pertonia  appears  '  i  melancholia 
and  in  the  depressive  stages  of  other  psychoses,  katatonic  tension,- 
in  hy])ochondric  paranoia,  in  delirium  hallucinatorium,  in  alco- 
holism, and  in  paresis;  hypotonia,  in  the  most  diverse  psychoses 
which  begin  with  paralysis,  besides  being  present  in  acute  de- 
mentia. 

Spasms  of  single  muscles,  likewise  general  and  tonic  spasms, 
are  observed  in  idiocy,  in  epileptic,  hysteric,  and  hystero-epileptic 
psychoses,  in  intoxication  psychoses,  as  well  as  in  the  organic 
psychoses,  and  are  discussed  under  their  respective  heads. 


Dishirhances  of  MoUliiij.  lOo 


The  same  is  true  ui  paralyses  wherever  they  may  be  localized, 
with  or  without  contractures.  At  this  juncture  the  paralytic 
states  of  the  bladder  and  rectum  may  also  be  discussed. 

Enuresis  (involuntary  discharge  of  urine)  appears  in  the 
insane : — 

\.  lU'Ciiusc  the  i);ili('nt  docs  not  pay  siilliciciii,  ;il  lent  ion  to 
the  need  of  urinating;  urination  follows  roHcxly,  as  in  playing 
children.  '^^I'his  form  oL'  enuresis  a])pears  in  the  demented,  in 
mania,  and  in  the  states  of  stupor  and  raving. 

2.  Because  the  feeling  of  fullness  of  the  bladder  is  dimin- 
ished or  extinguished.  The  urine  is  discharged  entirely  by 
means  of  reflex  action.  In  paretics,  in  senile  dementia,  and 
sometimes  in  stupor,  such  is  the  case. 

The  anesthesia  may  be  so  strong  that  the  patient  does  not 
notice  the  discharge  of  the  urine.     "Another  has  wetted  the  bed." 

3.  By  paralysis  of  the  sphincter  vesicse :  the  urine  nms  out 
constantly;  present  in  organic  psychoses. 

4.  In  states  of  unconsciousness  (epileptic,  paralytic  attacks). 
Ischuria  (retention  of  the  urine)  is  observed: — 

1.  In  anesthesia  of  the  bladder.  The  patient  does  not  notice 
that  his  bladder  is  full,  and  on  this  account  does  not  feel  any 
inclination  to  discharge  the  urine.  Along  with  this,  the  sphinc- 
ter may  be  closed  spasmodically  (here  belong  the  urine  retention 
of  melancholiacs,  of  many  in  stupor),  or  the  detrusor  vesicfc  may 
be  paralyzed  (organic  mental  diseases,  paralytic  attacks). 

2.  In  paralj'sis  of  the  bladder  reflexes  (paresis  and  other 
organic  mental  diseases). 

3.  In  consequence  of  delusions.  The  patient  is  forbidden 
to  discharge  urine,  or  he  does  not  like  to  soil  the  vessel. 

One  should  never  hesitate,  especially  with  demented  or  stu- 
porous patients,  to  examine  the  bladder.  Sometimes  the  urine 
is  dripping  continually,  while  the  bladder  is  distended  even  to 
the  umbilicus.  {Ischuria  paradoxa).  When  the  sphincter  is 
paralyzed,  the  urine  simply  trickles  mechanically  from  the  blad- 
der (paresis,  senile  dementia). 

The  circumstances  are  similar  in  regard  to  the  stools. 

Constipation  generally  accompanies  the  functional  ])sychoses. 


104  General  Symptomatology. 

It  is  esijecially  obstinate  in  nielancliolia,  and  generally  has  its 
basis  in  the  spasmodically  inhibited  peristalsis  and  the  hypertonic 
state  of  the  sphincter  (hence  in  this  condition  opium  often  aids 
the  defecation). 

But  sometimes  it  is  delusions  which  prevent  the  patients 
from  going  to  the  closet:  because  they  do  not  wish  to  defile  it, 
or  they  are  afraid  of  being  infected  there. 

Inroluntarj^  passage  of  the  stools  (secessus  involuntarii) 
may  take  place,  as  with  enuresis. 

In  regard  to  the  discharge  of  the  stools,  there  is  a  condition 
similar  to  ischuria  paradosa,  which  appears  especially  in  paresis 
— a  constant  flux  of  liquid  stools,  while  the  colon  is  filled  with 
hard,  firm,  fecal  masses   (scj'bala). 

The  "uncleanly,"^  who  pass  feces  and  urine  at  random,  who 
discharge  nothing  in  the  closet,  but  immediately  thereafter  soil 
their  clothing  and  bedding,  and,  as  soon  as  cleaned,  defile  every- 
thing again,  are  a  great  trouble  to  institutions.  Sometimes  the 
uncleanliness  is  premeditated,  arbitrary  (imbeciles  with  moral 
insanity,  paranoiacs;  occurs  very  rarely  for  simulation). 


5.  Disturbances  of  the  Reflexes. 

The  strength  of  the  tendon  reflexes  is  very  different  in  the 
different  functional  psychoses.  Xormally  the  strength  of  the 
patellar  tendon  reflex  varies  to  a  considerable  degree,  and  is 
generally  increased  according  to  nutrition,  while  in  the  highest 
degrees  of  cachexia  it  becomes  diminished,  or  may  even  dis- 
appear. 

There  is  often  exaggeration  of  the  tendon  reflexes  in  hys- 
teric and  epileptic  psychoses,  in  quite  a  number  of  cases  o? 
paresis,  in  the  psychoses  of  multiple  sclerosis;  unilaterally  ex- 
aggerated in  apoplectic  psychoses  or  in  the  same  with  focal  dis- 
eases. In  these  cases  a  patellar  or  foot  clonus  is  present  con- 
temporaneously. A  noteworthy  difference  in  the  strength  of 
the  patellar  reflexes  on  the  t«'o  sides  points  to  a  developing  or- 
ganic disease  of  the  spinal  cord  or  of  the  brain,  or  of  both,  and 


^  Manheimer.    Du  gatisme.    These  de  Paris,  1897. 


Disturbances  of  Lhe  Reflexes.  105 

is  often  observed  before  the  complete  disappearance  of  the  re- 
flexes (paresis,  senile  dementia). 

Absence  of  the  patellar  reflexes^  exists  very  rarely  in  normal 
individuals  (I  saw  this  once  in  a  man  and  his  fourteen-year-old 
son  without  any  other  symptom  of  a  nervous  disease),  and  it 
may  be  said  with  almost  absolute  certainty  that  the  lack  of  the 
patellar  tendon  reflex  in  one  mentally  diseased  points  to  an  or- 
ganic disease  of  the  nervous  system,  whether  it  be  a  neuritis 
(alcoholism,  diabetes,  kidney  affection),  or  to  a  disease  of  the 
posterior  columns  (especially  paresis  with  medullary  degener- 
ation), or  to  an  organic  change  in  the  posterior  cranial  fossa 
(cerebellar  tumors,  or  affections  of  the  pons). 

Sometimes  the  tendon  reflexes  seem  sluggish,  that  is,  the 
reflex  is  not  completed  quickly,  snappy,  lightning-like,  as  nor- 
mally, but  takes  place  slowly,  lazily,  a  phenomenon  which  often 
precedes  the  disappearance  of  the  patellar  reflex. 

One  should  examine,  besides  the  patellar  tendon  reflex,  the 
reflex  of  the  tendon  of  Achilles  and  that  of  the  triceps  tendon 
at  the  elbow. 

Of  the  sli7i  reflexes  one  should  examine  the  plantar  reflex, 
that  of  the  cremaster  and  the  abdominal  muscles. 

The  strength  of  these  reflexes  varies  greatly  under  normal 
conditions. 

They  are  often  very  lively  in  hysteric  and  epileptic  psychoses, 
frequently  weak,  on  the  contrary,  in  the  depressive  stages  of  the 
various  psychoses.  They  are  absent  in  peripheral  paralysis  of 
sensation  and  of  motility.  For  the  rest,  their  disappearance  gen- 
erally points  to  an  organic  disease,  just  as  the  disappearance  of 
the  tendon  reflexes  does,  though  the  former  are  often  retained 
where  the  latter  are  absent. 

Absence  on  one  side  points  to  a  cerebral  organic  affection 
(found  especially  in  apoplectic  psychoses). 

The  reflex  of  Bahinsl-i  (the  great  toe  is  not  flexed  as  nor- 
mally in  calling  forth   the  plantar  reflexes,  but   is   extended) 


^One  should  only  speak  of  siich  after  placing  the  person  to  be  ex- 
amined on  a  table  with  naked  feet  and  the  legs  hanging  down  laxly, 
while  during  the  strokes  on  the  tendon,  the  patient's  mind  is  occupied 
by  counting  or  otherwise. 


106  General  Symptomatology. 

points  to  an  organic  disease  of  the  central  nervous  system,  ac- 
cording to  present  observations. 

Of  the  mucous  membrane  reflexes,  the  most  important  to 
examine  are  the  conjunctival  reflex,  the  reflex  of  the  velum 
palati,  and  that  of  the  jiharynx. 

These  are  often  wanting  where  the  skin  reflexes  are  absent; 
moreover,  tliey  are  especially  absent  in  bystericals  and  alcoholists. 

Of  the  visceral  reflexes,  the  reflex  of  the  pupils,  of  the  blad- 
der, and  of  the  rectum  have  already  been  mentioned.  The  sexual 
reflex  is  often  exaggerated  in  maniacal  states,  also  in  those  of 
paresis;  otherwise  regularly  depressed  (often  even  in  the  incip- 
ient stages  of  paresis,  in  alcoholists,  morphinists,  in  all  depressive 
states),  and  generally  vanishes  entirely  in  organic  mental  dis- 
eases. 


6.  Disturbances  of  the  Vasomotor  Nerves.     Anomalies 
of  the  Secretions.     Trophic  Disturbances. 

Angiospastic  conditions  are  observed  in  the  insane  as  a  feel- 
ing of  coldiiess  on  the  head,  on  the  back,  of  the  hands  and  feet ; 
further,  as  local  asphyxia  of  the  hands  and  feet  (in  melancholia, 
also  in  other  depressive  states,  hysteric  and  epileptic  psychoses,  in 
paresis) .  Precordial  anxiet}^  is  also  brought  on  by  a  vasomotor 
neurosis. 

Appearing  in  a  slight  degree,  only  as  pressure  and  oppres- 
sion in  the  region  of  the  heart,  it  may  increase  to  a  feeling  of 
anxiety,  even  deathly  anxiety  (which  begins  with  a  small  accel- 
erated pulse),  the  Hippocratic  countenance  (which  later  on  be- 
comes hot  and  red),  cold  extremities,  retarded  and  superficial 
respiration  (seven  to  nine  inspirations  to  the  minute),  and  with 
a  general  trembling  of  the  body.  Towards  the  end  of  an  attack 
deep  and  sighing  respirations  set  in.  They  often  end  with 
copious  perspiration.  At  the  height  of  the  attack  there  is  quite 
often  a  certain  degree  of  mental  stupor. 

Pra?cordial  anxiety  is  most  frequent  in  melancholia,  but 
appears  also  in  the  depressive  stages  of  other  psychoses,  is  found 
in  epilepsy,  in  the  pre-  and  post-epileptic  states,  and  in  epileptic 
psychoses,  in  the  most  diverse  intoxications,  and  is  observed  in 
alcoholism  and  the  privation  morj)hine  cures. 


Trophic  iJisLurbances.  107 


Angio paralytic  states  appear  as  transient  reddenings  of  va- 
rious parts  of  the  body,  as  derinographia,  as  edema  (white  and 
pale  in  hysteric  psychoses),  as  cyanosis  of  the  skin  (in  idiocy, 
ill  the  later  stages  of  paresis),  as  miliary  hemorrhages  under  the 
^kin,  of  the  various  internal  organs  (also  bloody  sweats,  vomit- 
ing ))lood,  etc.).  One  slioiild  l)e  carci'ul  about  assuming  that 
giX'jiL  hcjiiorrhages  come  rniiii  jiervous  causes.  Wounds  which 
llie  patient  has  received,  or  which  he  has  inflicted  upon  himself, 
may  easily  become  a  source  of  deception. 

The  secretion  of  saliva  may  be  increased  in  the  insane  (in 
mania  with  tough  saliva  as  transparent  as  glass,  in  paresis,  in 
paranoia  with  delusions  of  poisoning,  saliva  is  abundant,  first 
watery,  then  thicker  and  darker;  further,  mercurial  psychoses)  ; 
or  it  may  be  diminished  (melancholia,  certain  intoxications). 

An  increase  of  the  saliva  is  sometimes  only  apparent,  since 
the  patient  does  not  swallow  the  saliva,  but  permits  the  wdiole 
quantity  to  flow  out  (stupor  conditions,  idiotism,  dementia). 

Increase  of  perspiration  (hyperhidrosis)  takes  place  some- 
times in  the  incipient  stages  of  paresis,  often  in  alcoholism,  in 
epilepsy,  especially  also  witli  and  after  paralytic  attacks. 

Diminution  of  perspiration  (liyphidrosis)  occurs  in  melan- 
cholia especially,  in  the  demented  states  of  the  most  diverse 
psychoses,  also  pronounced  in  myxedema. 

The  odor  of  perspiration,  which  was  once  attributed  to  the 
insane  as  a  peculiarity  (mouse  odor),  is  to  be  ascribed  to  un- 
cleanliness  or  to  the  foulness  of  tlie  patient's  breath  through  liis 
refusal  of  nourishment,  or  to  other  causes. 

The  apparent  trophic  disturbances  in  the  cutis  and  sub- 
cutaneous tissues  are  frequently  only  phenomena  of  uncleanli- 
ness  or  violent  action  (erythemas,  many  are  panaritias,  often  in 
very  insidious  forms;  many  are  cases  of  decubitus)  ;  sometimes 
they  appear  in  consequence  of  medication  (antipyrine,  chloral, 
bromides). 

On  the  other  hand,  it  does  not  seem  doubtful  that  in  organic 
psychoses,  especially  in  paresis,  the  tissues,  especially  the  bones 
and  the  cartilage,  should  undergo  such  a  change  that  very  slight 
wounds  or  even  violent  movements  should  result  in  fractures  or 
dislocations.  In  this  connection  the  blood-tumor  of  the  ear 
(othematoma)  is  to  be  mentioned  especially. 


108  General  Symptomatology. 

The  ear  cartilage  suffers  a  hyalin,  later  a  granular,  degener- 
ation. The  ears  assume  a  bluish  white  color.  Finally,  in  the 
aural  cartilage  a  partly  fibrillar,  partly  granular  disintegration 
arises,  and  a  liquefaction  with  the  formation  of  cavities  ensues. 

A  slight  blow,  a  bumping  of  the  ear,  grasping  the  same, 
may  start  a  rupture  of  the  vessels  in  the  wall  of  the  ca^^ty,  which 
is  partially  newly  formed,  and  an  othematoma  thereby  arises;  a 
tumor  which  appears  especially  in  men,  varying  from  the  size 
of  a  hazel  nut  to  that  of  a  hems  egg,  and  finally  leads  to  atrophy 
of  the  ear.  The  othematoma  appears  very  rarely  in  healthy 
persons  after  a  violent  trauma.  In  the  insane  it  arises  regularly 
after  a  wound  from  the  hand  of  an  attendant  (the  left  ear  cor- 
responding to  the  right  hand  of  the  attendant),  especially  in 
paretics,  but  also  in  epilepsy  and  senile  dementia,  very  rarely  in 
mania  with  fury. 

Similar  changes  are  observed  in  the  cartilage  of  the  nose 
(rhinhematoma),  also  in  the  cartilage  of  the  ribs  and  of  the 
joints. 

The  bones  of  the  insane  are  fractured  easily,  since  they  lose 
their  strength  as  their  osseous  substance  becomes  smaller  and  the 
medullary  canals  are  widened. 

Contemporaneousl}^  with  this  the  secretion  of  calcareous 
salts  ill  the  urine  is  increased. 

Decubitus  (bed  sores),  especially  in  the  form  of  decubitus 
acutus  and  acutissimus  and  malum  perforans,  are  caused  by 
trophic  disturbances  in  the  subcutaneous  tissues. 

The  decubitus  begins  with  an  erythema  on  which  vesicles 
with  dark,  reddish,  or  red-brown  contents  arise.  These  burst 
or  dry  up,  the  skin,  laid  bare,  becomes  infiltrated  with  blood, 
gangrenous,  and  puffed  out.  Sometimes  the  process  of  gangrene 
is  completed  in  a  single  night  (decubitus  acutissimus).  The 
decubitus  depends  upon  an  extended  neuritis.  The  sacral  region 
and. the  nates  are  most  often  affected,  but  bed  sores  develop  on 
the  elbows,  heels,  and  shoulders.  They  develoj)  with  especial 
frequence  in  paretics  after  a  paralytic  attack,  or  a  pneumonia, 
which  confines  them  to  their  beds. 

Trophic  disturbances  are  also  observed  in  the  lialr  (abnor- 
mal increase  of  the  growth  of  hair,  falling  out  of  the  hair,  alo- 
pecia areata;  becoming  gray  prematurely,  which  is  sometimes 


Anomalies  of  the  Internal  Organs.  109 


unilateral),  in  the  nails  and  the  teeth  (as  rapid  decay  and  falling 
out),  especially  present  in  organic  brain  diseases  and  in  paresis; 
it  is  also  often  seen  in  functional  psychoses  (see  circular  in- 
sanity; I  have  repeatedly  seen  alopecia  areata  in  paranoiacs,  in 
whom  the  system  of  delusion  was  indicated  by  the  falling  out 
or  groAvth  of  the  hair). 

With  the  trophic  disturbances,  see,  also,  bodily  Aveight. 


XI.  ANOMALIES  OF  THE  INTERNAL  ORGANS. 

Diseases" of  the  respiratory  apparatus,  especially  pulmonary 
tuberculosis,  appear  in  chronic  psychoses  favored  by  the  loss  of 
strength  or  by  direct  infection  in  the  institutions.  They  are 
not  to  be  considered  as  a  symptom  of  the  brain  affection. 

The  fetid  odor  of  the  respired  air  is  due  principally  to 
the  uncleanliness  of  the  mouth,  but  may  be  called  forth  by  re- 
fusal of  nourishment,  by  diabetes,  or  by  the  treatment  (sweetish 
odor  in  the  bromide  treatment,  paraldehyde  breath) . 

Changes  of  the  heart  muscles,  hypertrophy  of  the  left  ven- 
tricle and  dilatation  of  the  right,  are  often  found  in  psychoses; 
still  oftener,  premature  atheroma  of  the  arterial  system  (hard 
radial  walls),  serpentine  temporal  arteries,  and  accentuation  of 
the  second  aortic  sound  of  the  heart. 

The  frequency  of  cardiac  affections  in  psychoses  is  shown 
l)y  the  statement  of  Strecker  (Virchow's  Archiv,  Vol.  13G),  ac- 
cording to  which,  in  one  thousand  autopsies  made  at  Dalldorf 
Asylum,  pathological  changes  of  the  heart  were  found  in  61.7 
per  cent,  of  the  men  and  43.7  per  cent,  of  the  women. 

These  changes  are  partially  the  consequence  of  those  insults 
which  called  forth  insanity  {e.g.,  alcoholism,  kidney  affections), 
and  they  represent  partially  the  results  of  the  influence  of  the 
brain  disease  on  the  vasomotor  system;  finally,  they  are  to  be 
considered  in  part  as  etiological  factors  of  mental  disease  (see 
etiology) . 

The  pulse,  which  is  very  often  normal  in  the  insane  in  re- 
spect to  quality  and  frequency  (chronic  dementia),  may  be  in- 
creased in  frequency  (especially  in  psychoses  in  Basedow's  dis- 
ease, or  retarded  (apoplectic  attacks,  brain  tumors). 


110  General  Symptomatology. 

It  is  slow,  with  little  fullness,  in  depressive  states,  especially 
in  stupor,  yet  it  may  be  accelerated  in  melancholia.  In  the 
maniacal  states  it  is  often  accelerated  and  of  medium  fullness. 

Sphygmography  frequently  shows  in  the  organic  psychoses, 
anacrotic  and  catacrotic  heightenings,  and  a  slow  pulse;  for  the 
rest,  the  hopes  of  obtaining  weighty  conclusions  from  this  method 
of  examination  have  not  been  fulfilled. 

The  pressure  of  the  blood  is  generally  increased  in  the 
depressive  states  and  in  stupor,  while  it  is  decreased  in  maniacal 
excitement. 

The  composition  of  the  Mood  shows  only  slight  deviations 
from  the  normal;  these  are  dependent  upon  the  nourishment, 
otherwise  not  essential. 

Disturbances  in  the  functions  of  the  stomach  and  intestines 
are  almost  regular  companions  of  the  initial  stages  of  psychoses. 
They  appear  in  loss  of  appetite,  coated  tongue,  and  obstruction  of 
the  bowels.  In  the  functional  psychoses  a  change  of  this  con- 
dition sometimes  first  appears  with  convalescence. 

The  loss  of  appetite  increases  in  many  cases  to  refusal  of 
nourishment  {sitophohia). 

This  may  be  complete  or  partial;  in  the  latter  case  water 
or  liquid  nourishment  is  still  taken. 

Sitophobia  may  also  be  conditioned: — 

1.  By  the  absence  of  the  feeling  of  hunger  and  thirst  in 
maniacal  states  and  in  raving. 

2.  By  hallucinations  and  delusions. 

(a)  Melancliolic  nature.  The  patient  considers  himself  un- 
worthy to  eat ;  he  cannot  pay  for  the  food.  Voices  threaten  pun- 
ishment if  he  eats. 

(l)  Hypochondric  nature.  His  throat  is  tied,  his  body 
is  full,  nothing  passes  through  his  rectum,  he  is  afraid  of  burst- 
ing if  he  takes  more  food  into  his  stomach. 

Both  in  melancholic  and  hypochondric  insanity  the  delu- 
sion of  poisoning  may  be  the  cause  of  his  abstinence ;  this  cause  is 
observed  vpry  often  in  paretics  who  refuse- nourishment. 

(c)  Paranoic  nature.  The  patient  will  be  injured  by 
poison  or  filth  in  the  food,  or  he  must  prepare  himself  for  his 
divine  mission  by  fasting. 

(d)  In  stupor  (see  this). 


Anoinalles  of  ike  Internal  Organs.  Ill 

3.  By  lit  oughts  of  suicide.  The  patient  wishes  to  commit 
suicide  by  refusal  of  nourishment,  since  he  lacks  the  courage  or 
opportunity  to  destroy  himself  in  another  way. 

In  many  cases  the  patient  even  takes  the  liquid  food  into 
his  mouth,  moves  it  around  there,  then  spits  it  out  again;  as  in 
mania  and  in  delirium  acutum.  Often  the  patient  eats  secretly, 
believing  himself  unobserved,  while  he  resists  the  pressure  to 
induce  him  to  eat  (katatonic  stupor,  melancholia).  Others  allow, 
without  resistance,  food  to  be  placed  in  their  mouths  and  swallow 
it  slowly  (hypotonic  stupor). 

If  the  absolute  refusal  of  food  continues  for  some  days,  the 
expired  air  has  a  partially  decayed,  partially  aromatic  odor  which 
depends  upon  its  aceton  contents  (TuczeJc);  then  the  respiration 
becomes  more  superficial,  the  temperature  of  the  body  falls, 
amounting  before  death  to  only  84°  to  86°  F. 

The  weight  of  the  body  decreases  rapidly  the  first  week, 
about  1  to  1.5  kilogram  daily.  The  quantity  of  feces  and  urine 
is  diminished.  The  urine  shows  albumin,  is  very  acid  in  con- 
sequence of  the  increase  of  sulphuro-phosphoric  acid,  and  even 
after  thirty-six  hours  contains  considerable  quantities  of  aceton 
(Lahr).  There  follows  finally  a  fatty  degeneration  of  the  gland- 
epithelia  of  the  intestine,  and  atrophy  ensues.  Total  abstinence 
may  be  endured  for  twelve  to  fourteen  days  without  permanent 
injury;  abstinence,  except  from  drinking  water,  for  several 
weeks. 

The  belching  and  expulsion  of  atmospheric  air  is  often  ob- 
served in  the  insane  (especially  in  hysteric  psychoses,  in  the 
initial  stages  of  paresis,  in  hypochondric  psychoses,  in  para- 
noiacs,  to  rid  themselves  of  poison). 

Increased  appetite,  without  satiety,  bulimia,  are  observed  in 
idiotism  and  in  the  various  demented  states. 

The  urine  in  increased  excitement,  especially  in  mania  and 
the  maniacal  stages  of  paresis,  shows  absolute  and  relative  dimi- 
nution ol'  tJic  phosphoric  acid  (Mendel). 

Alhumin  is  frequently  found  after  epileptic  and  the  para- 
lytic attacks  of  paresis;  there  is  often  peptonuria  in  paresis. 

Svgar  is  seldom  found  (see  diabetic  psychoses).  . 

Ilenstruation  is  frequently  undisturbed  during  the  course 
of  chronic  psychoses. 


112  General  Symptomatology. 

On  the  other  hand,  it  is  often  wanting  at  the  beginning  of 
a  psychosis  in  a  young  person,  returns  irregularly  in  the  further 
course,  or  remains  absent  during  the  entire  duration  of  the  dis- 
ease and  first  appears  again  during  the  convalescence.  If  an  acute 
psychosis  affects  elderly  persons,  no  anomaly  of  the  menstruation 
is  to  be  observed.  In  periodical  psychoses  menstruation  is  reg- 
ularly undisturbed  or  shows  only  slight  irregularities. 

The  temperature  of  the  body  is  normal  or  subnormal  in 
chronic  psychoses.  A  rise  of  temperature  generally  points  to  a 
complication.  It  is  always  an  indication  for  the  physician  to 
examine  all  the  organs  most  carefully.  -It  rises  sometimes  ex- 
cessivel}^  especially  in  the  final  stages  of  paresis. 

Such  an  excessive  rise  of  temperature  appears  when  the 
psychosis  follows  the  type  of  delirium  acutum  (which  see). 
Great  depression  of  the  temperature  of  the  body  is  observed  in 
states  of  great  inanition  and  paresis. 

In  acute  psychoses  an  inverted  type  often  appears  (the  even- 
ing temperature  is  lower  than  the  morning  temperature),  and 
there  is  a  slight  abnormal  difference  between  the  temperature  of 
the  rectum  and  that  of  the  armpit  or  of  the  external  auditory 
canal  (Mendel).  The  inverted  type  is  especially  frequent  in 
hysteric  psychoses,  as  is  also  the  rapid  change  of  temperature 
during  the  intervals  of  normal  temperature. 

The  irciglit  of  the  hody  almost  always  diminishes  consid- 
erably in  the  initial  stage  of  an  acute  psychosis ;  this  is  often  so 
rapid  that  it  cannot  be  explained  solely  by  the  existing  disturb- 
ance of  the  gastro-intestinal  tract  and  insufficient  nutrition,  and, 
accordingly,  must  be  considered  as  a  trophoneurotic  s3'mptom. 
The  decrease  generally  persists  during  the  presence  of  the  acute 
psychosis,  and  the  increase  of  weight,  if  it  coincides  with  the 
diminution  of  the  morbidly  heightened  symptoms,  is  very  favor- 
able prognostically ;  yet  if  this  increase  coincides  with  a  weak- 
ening of  the  mental  functions,  it  points  to  the  beginning  of 
dementia  (see,  also,  circular  psychosis  and  paresis). 


The  ELioloyy  of  Menial  Diseases.  113 


B.     The  Etiology  of  Mental  Diseases. 

By  the  Prussian  census  of  1SU5  there  were  82,850  insane 
(43,448  men  and  39,402  women).  There  was  one  insane  person 
to  each  384  inhabitants  (1  to  360  among  the  males,  1  to  411 
among  the  females). 

The  census,  which  included  only  those  patients  in  institu- 
tions, does  not  give  a  complete  picture.  We  should  not  err  in 
reckoning  at  least  one  insane  person  to  300  inhabitants. 

In  England,  on  January  1,  1895,  there  were  38.95  insane 
persons  in  10,000  inhabitants,  consequently  1  to  250;  in  the 
Canton  of  Zurich,  in  1888,  1  to  103 ;  in  Hungary,  1895,  1  to  640. 

It  is  calculated  that  in  the  most  populous  centers  there  are 
about  three  places  in  1000  inhabitants  in  institutions  for  the 
insane,  and  two  places  for  the  inhabitants  of  the  country. 

On  the  1st  of  January,  1897,  there  were  in  Prussia  61,482 
patients  in  the  institutions  for  the  insane. 

[In  the  State  of  Kew  York,  on  October  1,  1905,  there  were 
in  the  State  hospitals  for  the  insane,  11,995  men  and  13,525 
women,  a  total  of  25,520. 

In  the  private  institutions  under  the  supervision  of  the 
State  Commission  in  Lunacy  there  were  367  men  and  618  women, 
a  total  of  985. 

In  the  two  hospitals  devoted  to  the  insane  criminals  (Mat- 
teawan  and  Dannemora),  there  were  814  men  and  89  women, 
a  total  of  903.  The  combined  totals  make  13,176  men  and 
14,232  women,  27,408  in  all.  The  population  of  New  York 
State  on  June  1,  1905,  was  8,066,672.  Hence  in  Few  York 
there  is  one  insane  person  to  295  inhabitants. — Ed.] 

According  to  the  enumerations,  mental  diseases  have  in- 
creased, and  undoubtedly  this  increase  is  for  single  forms,  as 
in  paresis.  But  these  enumerations  are  not  certain  proof,  nor 
are  the  constantly  increasing  greater  proportion  to  the  increase 
of  population,  admissions  to  the  institutions;  since  the  former 
are  gradually  becoming  more  exact,  but  the  latter  depends  par- 
tially on  general  social  conditions,  also  in  the  greater  or  less 
number  of  places  disposable  and  the  easier  entrance  into  the 
institutions. 


114  The  Etiology  of  Mental  Diseases. 


Epidemics,  times  of  general  mental  excitement  have  un- 
doubtedly an  influence  on  the  increase  of  the  number  of  the 
insane.  But  it  must  not  be  forgotten  that^  under  these  condi- 
tions, often  those  persons  who  were  already  mentally  diseased 
now  show  their  mental  calibre  and  are  for  the  first  time  recog- 
nized as  being  insane. 

The  number  of  men  mentally  diseased  is,  as  the  above  figures 
from  Prussia  show,  greater  than  the  number  of  insane  women. 
In  the  institutions,  also,  the  first  exceed  the  latter  in  number 
(January  1,  1897:  of  100  insane  in  Prussia,  5-i  were  male  and 
46  female). 

This  is  clue  in  great  measure  to  the  preponderance  of  paresis 
and  alcoholic  insanity  among  men. 

In  iSTew  York  State  the  female  sex  shows  the  greater  inclina- 
•tion  to  insanity,  in  the  ration  of  l-i  to  13. 

The  frequency  of  mental  disease  increases  constantly  from 
the  age  of  puberty,  is  greatest  in  men  at  the  age  of  forty  to 
fort3^-five  5^ears,  amounts  here  to  four  to  the  1000;  in  women 
about  fifty  years  old,  to  almost  four  to  the  1000. 

Unmarried  men  and  women  and  widows  become  diseased 
mentally  relatively  more  frequently  than  those  living  in  the 
married  state.  A  comparative  table  of  the  various  callings  can- 
not be  given,  from  want  of  certain  and  extensive  data. 

Undoubtedly  there  appears  to  be  a  greater  disposition  to 
insanity  and  diseases  of  the  nervous  system  among  the  Jews. 

In  the  great  majority  of  cases  the  insanity  is  the  product 
of  a  combination  of  causes,  and  only  in  a  part  of  the  intoxication 
psychoses  and  those  called  forth  by  trauma  does  a  single  etiolog- 
ical factor  seem  sufficient  to  produce  the  disease. 

We  distinguish: — 

1.  Predisposing  factors. 

2.  Factors  favoring  the  outbreak  with  an  existing  predis- 
position. 

3.  Direct  factors. 


Predisposing  Factors.  '  115 


1.  PREDISPOSING  FACTORS. 

Among  these  the  liercdilnry  ba,^i.^  has  by  far  the  greatest 
significance. 

[Heredity,  wlien  it  is  attributed  to  parents,  is  imme- 
diate; when  it  is  traced  from  grandparents,  having  skipped  the 
parents,  it  is  then  mediate  heredity.  When  it  has  existed  for 
many  prior  generations  it  is  called  cumulative  heredity.  It  may 
Ije  on  the  side  of  both  parents,  in  which  case  it  is  called  double 
or  from  convergent  factors.  When  it  is  from  one  parent  it  is 
simply  heredity,  either  paternal  or  maternal.  According  ■  to 
Esquirol  the  latter  is  the  more  serious  form  of  the  two;  it  is 
also  three  times  more  common. 

When  hereditary  insanity  appears  in  the  child  at  the  time 
that  it  appeared  in  the  parent,  it  is  called  homochronous.  When 
it  appears  in  children  before  it  is  seen  in  the  parent,  it  is  called 
anticipatory.  When  the  hereditary  taint  reveals  itself  by  a 
mental  disorder  identical  with  that  of  the  parent,  it  is  called 
homologous ;  when  it  is  modified  in  passing  from  one  generation 
to  another,  it  is  called  dissimilar,  or  transformed.  When  it 
becomes  more  and  more  intensified  by  transmission,  it  is  said  to 
be  progressive ;  if  it  is  alleviated  by  a  series  of  fortunate  crossings, 
it  is  regressive. 

The  diagnostic  value  of  a  hereditary  tendency  to  insanity 
depends  largely  on  its  degree.  Thus  the  insanity  of  one  parent 
would  indicate  a  less  degree  of  predisposition  than  that  of  one 
parent  and  an  uncle,  or  still  less  than  that  of  a  parent  and  a 
grandparent,  or  of  both  parents.  Again,  the  insanity  of  a  parent 
and  a  grandparent  with  an  uncle  or  an  aunt  in  the  same  line  may 
be  held  to  indicate  a  stronger  predisposition  than  even  the  in- 
sanity of  both  parents. 

The  significance  of  the  insanity  of  parents  will  depend  to 
a  large  extent  upon  the  period  of  its  onset.  The  insanity  of  a 
parent  occurring  after  the  birth  of  a  child,  if  it  arose  from  a 
cause  adequate  to  excite  it  without  previous  predisposition,  would 
be  held,  of  course,  as  of  no  value  in  the  formation  of  a  hereditary 
tendency. 

The  insanity  of  relatives  farther  out  than  parents,  uncles 
and  aunts,  brothers  and  sisters  and  first  cousins,  is  not  woi'th 


116  The  Etiology  of  Mental  Diseases. 

anything  except  in  corroboration  of  nearer  and  weightier  facts. 
But  the  influence  of  other  related  diseases  to  insanity  occurring 
in  those  near  akin,  such  as  eccentricity,  alcoholism,  epilepsy,  hys- 
teria, hypochondriasis,  vicious  or  criminal  tendencies,  may  be  of 
great  import. 

Among  nervous  diseases  proper,  vre  find  heredity  just  as 
strongly  represented  in  the  various  neuroses  as  was  found  for 
the  ps3'choses — there  are  transmitted  in  the  organism  certain 
diatheses  which  favor  certain  diseases,  such  as  Huntington's 
chorea,  Friedreich's  disease,  running  through  successive  gener- 
ations. These  diseases  are  termed  hereditary,  familial,  embry- 
onic, and  this  succession  is  what  is  meant  b}'  the  term  direct  he- 
redity or  organic  heredity.  The  severity  of  the  heritage  depends 
very  largel}'  upon  the  number  of  members  and  branches  affected. 
Here  again,  as  in  the  study  of  psychotic  heredity,  we  find  that 
maternal  transmissibility  far  exceeds  the  paternal. 

Indirect  heredity  is  heredity  by  transformation  from  other 
neuropsychic  diseases  and  is  more  common  but  of  less  conse- 
quence than  direct  heredity.  Given  a  neuron  feebly  endowed  with 
enduring  qualities,  it  is  not  improbable  that  any  condition  ca- 
pable of  reducing  the  general  health  may  act  with  unusual  viru- 
lence upon  it.  The  result  is  a  neuropathic  disposition,  or  a 
nervous  organization  with  a  tendency  to  peld  readily  to  undue 
strains  and  unusual  influences,  though  of  themselves  of  no  ma- 
terial importance.  There  are  propagated  from  parent  to  off- 
spring certain  diatheses  which  favor  certain  neuropathic  equiv- 
alents. Thus  epilepsy,  melancholia,  or  inebriety  may  favor  the 
production  of  hysteria,  chorea,  or  neurasthenia  in  the  succeeding 
generations ;  the  transformation  of  the  neuroses  and  toxic  diathe- 
ses in  propagation  result  often  in  imbecility.  Thus  the  children 
of  hysteric,  epileptic,  hypochondric,  and  syphilitic  or  alcoholic 
parents  are  liable  to  be  imbecile.  Phthisical  parents  also  fre- 
quently beget  imbecile  children. 

Alcoholic  or  morphinistic  parents,  parents  who  were  in  a 
state  of  drunkenness  at  the  time  of  conception,  or  who  were 
considerably  weakened  by  general  diseases,  or  who  married  within 
proscribed  degrees  of  consanguinity,  transmit  to  the  germ  in  utero 
the  hereditary  predisposition  which  later  on  results  in  mental 
impairment. — Ed.] 


Predisposing  Factors.  11' 


In  many  cases  a  series  of  the  factors  mentioned  acts 
concertedly.  The  heredity  becomes  cumulative,  the  taint  stamped 
upon  tlie  descendants  works  progressively  and  culminates  in  the 
extinction  of  the  family. 

A  man  of  fifty  years,  who  is  an  alcoholist,  marries  his  niece, 
who  is  twenty  years  old.  Among  the  antecedents  epilepsy  is 
repeatedly  present.  Three  daughters  are  the  fruit  'of  the  mar- 
riage, who,  when  I  saw  them,  were  eleven,  nine,  and  seven  years 
old,  and  all  three  were  epilepto-idiotic. 

Sometimes  the  hereditary  basis  causes  such  changes,  even 
in  the  fetus,  that  the  child  is  born  incapable  of  mental  develop- 
ment, or  only  in  a  limited  degree  (congenital  idiocy)  ;  in  the 
great  majority  of  cases  the  hereditary  basis  forms  only  a  predis- 
position for  the  mental  disease,  which  arises  later  and  which 
needs  specially  favorable  momenta  and  direct  causes  for  its 
outbreak.  In  many  families  the  outbreak  in  the  different  mem- 
bers always  occurs  at  a  certain  age. 

Among  the  various  forms  whose  outbreak  is  favored  by  the 
hereditary  basis,  the  j)eriodic  and  circular  psychoses  take  the 
first  place ;  in  the  great  majority  of  cases  the  antecedents  of  these 
patients  show  a  long  line  of  mental  diseases  and  severe  central 
neuroses. 

The  hereditary  basis  generates,  beside  the  predisposition  to 
mental  disease,  certain  peculiar  natures,  who,  although  they  can- 
not be  called  mentally  diseased,  deviate  from  their  youth  up  iu 
their  thoughts  and  actions  from  the  average  man,  and  who  are 
therefore  called  inheritors,  also,  recently,  degenerates,  and  who 
show  quite  often  certain  bodily  abnormalities  (see  stigmata  of 
degeneration). 

These  individuals  may  reach  a  great  age  Avithout  becoming 
mentally  diseased,  but  they  are  placed  continually  during  their 
lives  as  if  in  a  balance,  where  they  endeavor,  not  without  diffi- 
culty, to  preserve  their  mental  equilibrium.  Often  enough 
special  occurrences,  misfortunes  of  all  kinds,  want  and  care, 
unhappy  love,  and  the  like,  disturb  that  equilibrium  and  generate 
transitory,  relapsing,  or  enduring  mental  diseases. 

Dissimilar  as  are  the  clinical  types,  and  however  great  the 
manifold  varieties  of  these  individuals  who  are  not  mentally 


118  The  Eiiology  of  Menial  Diseases. 

diseased  but  simply  inheritors,  they  may,  nevertheless,  be  all 
included  in  three  groups : — 

1.  Inheritors,  who  from  youth  up  are  dissatisfied,  first  with 
everything  connected  with  their  families,  then  with  the  whole 
world;  who  declare  that  everything  is  worthless  and  that  life 
is  not  worth  the  living,  and  that  suicide  is  the  only  thing  which 
is  right.  "While  they  wish  in  their  family  circle  to  pose  as 
martyrs  of  this  life,  they  appear  as  jovial  companions  in  good 
company  and  while  away  in  pleasure  many  hours  of  their  "hor- 
rors of  existence." 

They  perform  their  tasks  promptly,  liut  in  the  meanwhile, 
if  they  are  not  guided  by  a  firm  hand,  lose  their  energy^  and  then 
long  intervals  of  inactivit}'  follow. 

They  are  almost  always  making  hypochondrie  complaints, 
sometimes  becoming  exacerbated,  and  meanwhile  the  threatening 
spectre  of  mental  disease  plays  the  chief  role,  which  often  enough 
places  the  revolver  in  their  hands. 

2.  Inheritors  who  mature  mentally  very  early  with  special, 
often  limited,  endoAvments;  who,  however,  in  reference  to  their 
motives  as  well  as  endeavors  show  a  decided  irritability.  This  is 
expressed  by  the  imjjulsiveness  of  their  actions  and  by  the  rapid 
seizure  of  certain  ideas,  violent  striving  for  their  lulfiUment,  and 
again  by  sudden  relaxation  and  abandonment  of  what  they  have 
gained  by  their  struggles.  Much  is  begun  and  little  accom- 
plished. With  this,  there  is  quite  often  excessive  caprice,  in- 
consideration,  sometimes,  also,  extreme  sentimentality. 

In  this  class  belong,  also,  those  inheritors  in  whom  the 
motive  for  an  action,  for  a  crime  even,  does  not  at  all  correspond 
to  the  importance  and  the  difficulty  of  the  action.  The  strength 
of  the  impulse  replaces  the  weakness  of  the  motive. 

3.  Inheritors  who  are  popularly  styled  "originals"  or  "per- 
verted geniuses,"  from  their  appearance  in  society,  their  singular 
habits,  their  oddities,  their  peculiar  conceptions  and  oiDinions, 
which  they  exploit  with  consummate  skill,  notwithstanding  the 
fact  that  such  ideas  are  diametrically  opposed  to  the  general 
view. 

The  different  varieties  of  these  inheritors,  in  addition  to  the 
earlier   mentioned   physical   marks   of    degeneration   which    are 


Frcdl.sjiosliKj  Factors. 


119 


present  in  greater  or  less  numbers,  show  symptoms  of  phobias 
and  obsessions. 

Uterine  heredity.  Injuries  which  the  mother  receives  dur- 
ing pregnancy,  both  those  of  psychic  nature  (fright,  sorrow)  and 
diseases  of  various  kinds,  whether  they  are  acute  or  permanent 
(intoxications:  alcohol,  syphilis),  may  impart  to  the  child  hered- 
itary predisposition  to  mental  diseases. 

[The  frequency  of  heredity  among  the  insane  is  variously 
stated  by  different  authors,  the  percentage  ranging  from  30  to 
90  per  cent.  In  the  functional  psychoses  it  may  amount  to  TO 
per  cent. 

In  studying  the  percentage  of  heredity  as  noted  in  the  New 
York  State  hospitals  for  the  insane^  for  the  year  1899-1900  and 
since  October,  1888,  the  following  figures  were  obtained : — 

EECAPITULATION 


1899-1900 

Since  October  ] 

,  1888 

Institutions 

No 

No 

Heredity 

Exclusive 

heredity, 

Heredity 

Exclusive 

heredity, 

of  whole 

of  unas- 

exclusive 

of  whole 

of  unas- 

exclusive 

number 

certained 

of  unas- 
certained 

number 

certained 

of  unas- 
certained 

Utica  S.  H 

26.5 

33.8 

30. 
41.1 

70. 

58.8 

29.6 

28.6 

51.4 
46.8 

48  5 

WiUard  S.  H 

53.5 

Hudson  Rivei  S.  H.   .  . 

34.7 

44.5 

55.4 

27.5 

53.3 

46.6 

Middletown  S.  H 

26.4 

28.2 

71.7 

29.4 

31.6 

68  7 

Buffalo  S.  H 

24.7 

80.9 

69. 

21.1 

31.6 

68.3 

Binghamton  S.  H.    .  .  . 

36.2 

40.1 

59.8 

33.9 

43.4 

56.5 

St.  Lawrence  S.  H.   .  .  . 

35.8 

52.1 

47.8 

33.8 

50.7 

49.2 

Eocliester  S.  H 

31.6 

34  1 

65.8 

27.4 

:^9. 

60.9 

Long  Island  S.  H.    .  .  . 

17.5 

33.9 

09. 

15.7 

32.6 

67.3 

Manhattan  S.  H.  East  . 

13.4 

14.2 

82.7 

13.1 

18.1 

75.9 

Manhattan  S.  H.  West. 

11.7 

14.1 

85.7 

14. 

18.6 

81.5 

GowandaS.H 

28.5 

36. 

63.9 

31.2 

42.9 

57. 

Matteawan  S.  H 

15.4 

76.4 

23.2 

15. 

56. 

43.9 

Percentage  showing  heredity,  1899-1900,  25.8;  since  1888, 
24.5. 

Percentage  showing  heredity,  exclusive  of  unascertained 
cases,  1899-1900,  36.6;  since  1888,  39.7. 

Percentage  showing  no  hereditary  tendency,  exclusive  of 
unascertained  cases,  1899-1900,  63.3 ;  since  1888,  59.8. 


^  William  C.  Krauss,  American  Jouniul  of  Insanity,  April,  1902. 


120  Tlic  Etloluijii  of  ^lenial  Diseases. 

Total  number  of  cases  admitted,  1899-1900,  6361;  since 
1888,  61,257. 

Total  number  of  hereditary  cases,  1899-1900,  1203;  since 
1888,  11,526. 

The  hospital  showing  the  highest  percentage  of  heredity  of 
the  whole  number  for  the  year  1895-1896  was  the  Matteawan 
Hospital  with  a  percentage  of  57.1;  for  the  year  1898-1899,  the 
St.  Lawrence  Hospital  with  a  percentage  of  11.6 ;  for  the  year 
1899-1900,  the  Binghamton  Hospital  with  a  percentage  of  36.2  ; 
and  since  1888,  the  St.  Lawrence  Hospital  with  a  percentage  of 
33.8. 

Exclusive  of  the  unascertained  cases,  the  St.  Lawrence  Hos- 
pital showed  the  highest  percentage  for  the  year  1898-1899,  with 
56.6;  for  the  year  1899-1900,  the  Matteawan  Hospital  with  a 
percentage  of  76.1;  and  since  1888,  the  Matteawan  Hospital 
with  a  percentage  of  76.4. 

The  lowest  percentage  of  heredity  for  the  year  1895-1896 
was  shown  by  the  Manhattan  State  Hospital  with  a  percentage 
of  17.3;  1898-1899,  the  Matteawan  Hospital  with  a  percentage 
of  T5.3;  1899-1900,  the  Manhattan  Hospital  West,  with  a  per- 
centage of  11.7 ;  and  since  1888,  the  Manhattan  Hospital  East, 
with  a  percentage  of  13.1. 

Exclusive  of  the  unascertained  cases,  the  Manhattan  Hos- 
pital showed  the  lowest  percentage  for  the  3'ear  1898-1899 ;  the 
Manhattan  Hospital  West,  for  the  year  1899-1900,  with  a  per- 
centage of  14.1;  and  since  1888,  the  Manhattan  Hospital  East, 
with  a  percentage  of  18.1. 

These  percentages  vary,  of  course,  from  year  to  year,  and 
the  percentage  of  the  whole  number  since  1888,  as  39.7,  is  per- 
haps as  correct  an  index  of  the  true  percentage  as  it  is  possible 
to  determine. — Ed.] 

Besides  the  hereditary  basis,  the  environment  in  which  the 
child  is  reared  and  educated  undoubtedly  plays  an  important 
part  in  the  predisposition  to  mental  diseases. 

Many  psychic  peculiarities,  many  so-called  "stigma  hered- 
itatis"  do  not  arise  through  heredity,  but  from  imitation  in  child- 
hood, through  vicious  environment,  or  by  faulty  training.  That 
the  so-called  "cramming"  in  the  schools  pla3's  an  essential  part 
in  generating  mental  diseases  is  not  to  be  accepted,  but  the  fact 


Predisposing  Fdrlars.  121 


should  rather  be  considered  that  many  parents  force  their 
slightly  gifted  children  into  the  higher  schools  which  prepare 
for  the  learned  professions,  and  seel<  to  keep  them  there  by  pri- 
vate lessons,  that  is,  they  overexert  a  weak  organ  and  demand 
from  it  labors  which  do  not  correspond  to  its  development. 

MoreP  has  designated  as  a  degenerate,  one  whose  brain  and 
nervous  system  are  unstable,  from  inherited  or  acquired  taint  in 
the  parents,  who  lias  in  consequence  undergone  imperfectly  the 
embryological  changes  to  a  higher  type  in  tissues  or  organs,  and 
therefore  exhibits  tendencies  liable  to  extinguish  the  race  as  a 
type  under  the  usual  conditions  of  the  struggle  for  existence. 
Since  then  the  words  degeneration  and  degenerescence  have  been 
much  extended  in  psychiatry;  "degenerescence"  has  been  diag- 
nosed through  the  presence  of  characteristic  physical  stigmata  or 
from  certain  pathological  psychic  occurrences.  Sommer  is  per- 
fectly correct  when  he  thinks  that  the  conception  of  stigmata  of 
degeneration  has  been  so  extended  that  at  the  present  time  there 
is  no  living  man  who  could  not  be  declared  a  degenerate  on  this 
basis. 

If  one  conceives  the  hereditary  basis  in  its  broadest  sense 
as  it  has  been  described  above,  it  appears  to  me  that  by  far  the 
greater  part  of  the  "degenerates"  are  none  other  than  those  per- 
sons who  show  certain  physical  or  certain  mental  abnormalities, 
or  abnormalities  of  both  sorts,  in  consequence  of  hereditary  taint. 

But  when  one  speaks  of  an  "acquired  degeneration,"  and  by 
that  does  not  mean  the  demonstrable  pathologico-anatomical  de- 
generation of  the  nervous  system,  then  every  incurable  mental 
disease  is  "a  marked  deviation  from  the  type  which  may  be  in- 
herited."- According  to  this,  all  incurable  mental  diseases  may 
be  called  degeneration  psychoses. 

Everything  that  weakens  the  organism,  and,  by  this,  the 
nervous  sj^stem  also — the  most  diverse  somatic  diseases,  a  dissi- 
pated life,  onanism,  excesses  in  drinking  and  debauchery,  abuse 
of  tobacco,  traumata  of  the  cranium — may  cause  a  predisposition 
for  the  later  development  of  mental  disease. 


^Traite  des  degenereseenees.     Paris,  1857,  p.  4. 
2  Mobius,  Ueber  Entartung,  Bergmann,  1900. 


122  Tlic  Eliulufjij  of  Menial  Diseases. 


II.  THE  FACTORS  FAVORING  THE  BREAKING  OUT 
OF  THE  DISEASE  WHEN  THE  PREDISPOSITION 
IS  PRESENT 

lie,  above  all,  in  certain  ages  and  conditions  of  the  organism, 
which  offer,  according  to  experience,  a  favorable  basis  for  the 
development  of  diseases  of  the  nervous  system. 

1.  Puberty.^ 

Hereditary  taint,  often  connected  with  anemia  and 
onanism,  also  infectious  diseases,  previous  traumata  of  the  head, 
form  generally  the  basis  on  which  psychoses  may  develop  at  an 
age  from  twelve  to  twenty  3'ears,  which  is  designated  as  the  period 
of  puberty.  These  show  the  most  diverse  forms.  Most  frequently 
they  are  of  hysteric  nature ;  often  an  epileptic  psychosis  develops 
at  this  period,  especially  where  there  have  been  epileptic  seizures 
or  where  they  reach  the  point  of  breaking  out. 

Then  mania  or  melancholia  appears,  especially  the  h}'po- 
chondrie  form;  delirium  hallucinatorium ;  typical  paranoia 
seldom  develops  at  this  early  stage,  yet  its  primordial  form,  whose 
beginning  reaches  back  to  the  time  of  childhood,  generally  stands 
out  more  prominently  with  its  symptoms  in  the  period  of  puberty. 

While  the  functional  psychoses  of  childhood  are  distin- 
guished by  symptoms  corresponding  to  the  limited  stock  of  ideas 
in  the  undeveloped  brain,  hallucinations  and  delusions  do  not 
show  the  manifold  Uye  which  they  do  in  adults.  Xevertheless, 
the  age  of  puberty  sets  up  single,  determined  characteristics 
Avhich  owe  their  origin  to  the  undeveloped  mental  structure  and 
to  the  approaching  physiological  change  in  the  mental  sphexe. 
Herewith  are  connected  the  insipid  contents  of  the  delusions, 
the  elaboration  of  the  fairy  tales  read  during  this  period,  the  very 
unsteady,  frequently  changing  emotions  according  to  the  petu- 
lant childish  nature. 

The  peculiar  course  of  such  psychoses  appearing  at  the  time 
of  puberty  has  been  designated  by  the  names  of  JiehepJirenia 
(Kahlbaum,  Hecker)  and  Icatatonia  (Kahlbaum).  Eecently 
AschaffenbursT  has  contended  for  the  identitv  of  the  two  forms 


^Wille.     Ps^ycliobeu  d'js  I'uLerliltsalters.     Lfiiizig-Wieu,  1897. 


FacLors  Favurahle  io  Ouibreuk.  123 


and  has  united  them  under  the  name  of  dementia  prcecox 
(Kraepelin). 

In  the  cases  to  be  reckoned  here  one  is,  as  a  rule,  confronted 
l)y  persons  severely  tainted  hereditarily  who  were  exposed,  even 
in  childhood,  to  debilitating  influences,  especially  to  mental 
exertion  not  corresponding  to  the  powers  of  the  individual,  and 
to  faulty  rearing.  With  these,  onanism,  great  loss  of  blood  at 
the  beginning  of  menstruation  are  generally  present.  The  dis- 
ease commences  almost  regularly  with  a  hypochondric  depres- 
sion; the  patients  feel  themselves  incapable  of  labor,  are  back- 
■\vard  at  school,  complain  of  sleeplessness,  headaches,  sometimes 
of  palpitation  of  the  heart,  show  loss  of  appetite,  while  physical 
examination  does  not  disclose  any  disease.  They  distinguish 
themselves,  contrary  to  their  former  conduct,  by  refractoriness, 
disobedience,  disrespect  to  their  parents  and  to  their  teachers. 
Often  this  stage  is  not  recognized  as  pathological,  the  children 
are  despised  as  lazy  and  ill-bred,  often  punished,  or  allowed  by  in- 
dulgent parents  to  do  as  they  please.  Quite  often  it  goes  on  in 
this  way  for  an  indefinite  time. 

In  other  cases,  which  are  preferably  classified  with  katatonia, 
a  manifestly  pathological  mental  state,  which  is  acute  or  sub- 
acute, appears,  in  the  majority  of  cases  of  a  hypochondric  or 
melancholio-hypochondric  nature,  with  self-accusations  and 
delusions  of  transgression.  Sometimes  the  initial  delusions  be- 
long to  the  delusion  of  persecution  and  detraction. 

In  its  further  course  a  maniacal  or  stuporous  state  follows 
the  melancholic,  in  both  hebephrenia  and  katatonia ;  the  most 
diverse  states  may  also  interchange  irregularly.  Hallucinations 
are  present.  The  katatonic  stupor,  in  which  with  seeming  uncon- 
sciousness an  arrogant  temper  may  be  suddenly  expressed  with 
all  sorts  of  tricks  and  jests,  has  already  been  described.  With 
these  pathological  psychic  phenomena  is  connected  a  series  of 
symptoms,  which  have  been  specially  designated  as  katatonic. 
These  consist  of  muscular  tension  in  stereotA'ped  postures  and 
movements,  in  pathetic  speeches  with  verbigeration  and  perse- 
veration, in  a  passive  resistance  to  everything  which  is  desired 
of  the  patient,  to  every  movement  wliich  he  sliould  make  (nega- 
tivism), in  mutacism,  in  single  grotesque  and  bizarre  movements, 
as  clapping  the  hands,  rocking  the  head;  further,  in  sudden 


124  The  Etiology  of  Mental  Diseases. 

instinctive  actions,  measureless  abuse,  suddenly  striking  those 
about  liini,  throwing  articles  about,  also  attempts  at  suicide. 

Later,  in  a  great  majority  of  cases,  this  state  passes  quite 
rapidly  into  a  condition  of  idiocy,  and  one  may  designate  the 
dementia,  on  account  of  this  course,  as  dementia  prcecox. 

With  the  appearance  of  the  above-mentioned  phenomena  in 
this  dementia  there  is  developed  a  strikingly  petulant  disposi- 
tion, a  characteristic  type,  with  grimaces,  nonsensical  playing 
upon  syllables  and  words.  With  this,  the  patient  smiles  without 
expression  and  childishly,  cares  for  nothing,  passes  feces  and 
urine  involuntarily,  and  sometimes  sits  or  lies  for  weeks  in  one 
position. 

Yet  in  a  series  of  cases  dementia  does  not  enter,  but  there 
is  formed  a  certain  mental  weakness,  which  does  not  hinder  the 
patient  from  taking  up  some  calling  or  busying  himself  at  some- 
thing he  has  worked  at  before.  But  with  this  outcome  there  is 
always  a  certain  indifference  to  his  surroundings,  a  prominence 
of  egoistic  feelings,  a  certain  limitation  in  regard  to  the  object 
he  is  pursuing.    The  memory  may  meanwhile  remain  good. 

In  other  cases,  finally,  the  hebephrenic  and  katatonic  states 
are  cured,  and  the  patient  may  remain  exempt  from  relapses  dur- 
ing the  rest  of  his  life. 

Exceptionally  this  symptom-complex  also  appears  before 
puberty  at  the  age  of  from  ten  to  eleven  years,  sometimes  after 
the  years  of  puberty,  at  twenty-five  years  of  age  and  later.^ 

The  katatonic  symptoms  described  appear  not  only  in  the 
katatonic  psychoses  of  puberty,  but  they  also  appear  as  transitory 
symptoms  in  older  persons  in  the  course  of  delirium  hallucina- 
torium,  in  chronic  paranoia,  in  the  course  of  hysteric  and  epilep- 
tic psychoses,  in  paresis.  Sometimes,  also,  they  show  them- 
selves in  the  depressive  stage  of  cyclic  psychoses. 

At  the  age  of  puberty,  also,  the  mental  development  stops 
entirel}',  without  the  development  of  prominent  pathological 
psychic  phenomena.  Nothing  new  is  acquired,  and  imbecility 
thus  supervenes. 

Moreover,  the  cases  of  melancholia,  mania,  delirium  hallu- 


1  Tn  regard  to  the  frequency  of  this  dementia  pnecox,  according  to 
my  experience  in  Berlin,  it  amounts  to  about  2  to  3  per  cent,  of  the  in- 
sane observed. 


Factors  Favorable  to  Outbreak.  125 

cinatorium  at  puberty,  which  show  no  katatonic  symptoms,  offer 
a  serious  prognosis,  since  these  diseases  come  on  at  other  periods 
of  life.  They  frequently  incline  to  periodicity,  or,  if  this  is  not 
the  case,  to  jelapse  in  later  years,  and  pass  into  incurable  de- 
mentia, if  not  after  the  first,  then  after  the  second  or  third  re- 
lapse. 

2.  The  Climacteric  ^ 

which  comes  on  between  the  forty-fifth  and  fiftieth  year  in  the 
great  majority  of  cases,  favors  by  its  numberless  nervous  dis- 
turbances the  development  of  melancholias,  hysteric  psychoses 
with  maniacal  excitement,  especially  frequent  also  the  most  di- 
verse forms  of  paranoia,  often  with  sexual  delusions,  seldom 
mania  or  circular  psychoses. 

The  jisychoses  generally  begin  before  the  cessation  of  men- 
struation; they  show  at  first  the  oft-mentioned  fear  that  severe 
diseases  may  follow  the  cessation  of  menstruation,  and  thus  show 
a  hypochondric  character.  Quite  often  there  is  an  inclination 
to  suicide.  Sexual  desire  is  generally  heightened  in  women  be- 
fore the  cessation  of  the  menses  and  is  diminished  afterwards. 

In  men,  also,  one  may  speak  of  climacteric  psychoses,  which 
usually  appear  at  a  somewhat  later  age  than  in  women,  between 
the  fifty-fifth  to  sixtieth  years  (see  arteriosclerotic  psychoses). 

3.  Old  Age  2 

which  calls  forth  many  marks  of  mental  change  in  consequence 
of  the  physiological  involution  of  the  brain,  favors  the  appear- 
ance of  functional  mental  disease,  which  in  the  great  majority 
of  cases  comes  on  in  the  form  of  melancholia  with  hypochon- 
dric or  melancholic  self-accusations,  the  delusion  of  poverty, 
great  lack  of  energy;  and  with  all  these  there  is  mingled  vivid 
impulsiveness,  after  sleeplessness,  dizziness,  and  headache  have 
shown  themselves  as  prodromes.  The  melancholias  are  fre- 
quently of  a  very  obstinate  nature,  may  last  one  and  a  half  to 
two  years,  and  even  then  may  terminate  in  recovery.    Attempts 


"^Matusch.     Zeitschrift  fiir  Psychiatrie,  vol.  xlvi,  1890. 
^  Fuerstner.     Arehiv   fiii"    I'syfhiatrie,  vol  20.     Zingerle.    Jahrbnrli 
fiir  Psychiatrie,  1899,  p.  256. 


126  The  Etiology  of  2Iental  Diseases. 

at  suicide,  and  suicide,  are  quite  frequent  in  these  patients. 
Delirium  hallucinatorium  and  mania  appear  in  old  age.  I  saw 
a  mania  cured  which  appeared  in  the  eightieth  year.  Functional 
paranoic  states,  with  the  delusion  of  persecution,  .jealous  delu- 
sion, are  rare;  sometimes  circular  psychoses  are  developed. 

Senile  dementia  founded  on  an  organic  basis  (which  see) 
appears  much  more  frequently  as  a  psychic  disturbance  in  old 
age. 

If  one  assumes  old  age  in  general  as  beginning  with  the 
eighth  decennium,  there  are  also  cases  of  premature  senescence 
with  the  corresponding  mental  changes  which  even  appear  in 
the  first  years  of  the  seventh  decennium.  In  many  families  the 
mental  disorganization  regularly  shows  itself  about  the  sixty- 
fifth  year  of  life. 

4.  Pregnancy.^ 

The  psychosis  begins  sometimes  with  the  commencement  of 
pregnancy  and  ceases  afterwards.  It  generally  appears  first  in 
the  middle  of  pregnancy,  and  does  not  terminate  with  delivery, 
but    continues    into    the    puerperium.     We    especially    observe 

choreic,  uremic  ps3'clioses,  melancholia,  preferably  in  the  h3'po- 
chondric  form,  seldom  mania  and  paranoia. 

5.  Parturition. 

sometimes  calls  forth  a  transitory  disturbance  of  the  mind,  with 
unconsciousness,  which  generally  arises  from  a  hystero-epileptic 
or  uremic  basis;  but  even  without  this  it  may  proceed  from 
psychic  influences  (illegitimate  births)  or  by  violent  pain. 

6.  Puerperium.- 

The  psychoses  appearing  in  the  puerperium  may  be 
caused : — 

1.  By  a  feverish  puerperal  infection:  metritis,  endometritis, 
endocarditis  ulcerosa,  pyemia,  very  seldom  osteomalacia   {infec- 


^  Fiirstner.  Arcliiv  fiir  Psychiatrie,  a-o1.  5.  Mongeri.  Zeitschrift 
flir  Psychiatrie.  vol.  58,  1901. 

-  Siegentlialer.  Jahrbiich  fiir  Psychiatrie.  1S9S.  Aschaffenburg. 
Zeit-chrift  fiir  Psvchiatrie,  vol.  58.  Mever.  Klinische  Wochenschrift, 
1901,  xxxi. 


Factors  Favorable  to  Outbreak.  127 


liuus  puGvperal  psyckoacs).  These  psychoses  begin  regularly  two 
to  four  days  after  labor.  According  to  the  nature  of  the  basic 
process,  they  may  rapidly  lead  to  death  with  phenomena  of  de- 
lirium acutum. 

2.  By  uremia  with  eclampsia;  alcoholism  or  morphinism. 

3.  By  an  organic  brain  disease,  meningitis,  encephalitis, 
capillary  embolism. 

•i.  When  hysteria  or  epilepsy  has  been  present,  hysteric  or 
epileptic  psychoses  may  show  themselves. 

5.  With  a  predisposition  existing,  especially  with  hereditary 
taint,  the  puerperium  may  favor  the  development  of  a  functional 
psychosis,  which  far  most  frequently  runs  under  the  type  of  de- 
lirium hallucinatorium,  but  also  as  melancholia,  mania,  paranoia 
hallucinatoria  acuta  with  transition  into  chronic  paranoia.  In 
youthful  primiparge  sometimes  a  katatonic  symptom-complex 
develops.  In  all  these  cases  fever  is  entirely  lacking  during  the 
puerperium.  Such  a  phychosis  appears  preferably  in  primiparge 
when  the  birth  takes  place  at  an  advanced  age.  The  commence- 
ment of  the  psychosis  generally  dates  from  the  first  days,  or  at 
least  in  the  first  week,  of  the  puerperium. 

Often  such  a  psychosis  remains  solitary  throughout  life. 
Sometimes,  after  it  is  cured,  the  disease  is  repeated  in  the  same 
or  another  form  at  the  next  delivery;  in  other  cases  it  forms  a 
point  of  departure  for  relapsing  or  periodic  and  circular 
psychoses;  finally,  a  certain  percentage  pass  into  dementia  (20 
per  cent.)  after  a  relapse  of  the  psychosis.  The  average  duration 
of  the  functional  puerperal  psychoses  which  are  cured  amounts 
to  five  or  six  months. 


7.  The  Period  of  Lactation 

may  call  forth  a  psychosis  (delirium  hallucinatorium,  melan- 
cholia, paranoia)  by  exhaustion  or  psychic  influences  in  those 
predisposed.  In  the  majority  of  cases  this  occurs  in  the  sixth 
to  eighth  month  after  parturition. 


128  The  Etiology  of  Mental  Diseases. 


III.  DIRECT  CAUSES. 

Among  the  direct  causes  of  tlie  psychoses,  the  principal  ones 
from  their  importance  and  frequency  are 


1.  The  Psychic. 

They  are  either  of  sudden  or  gradual  eifect.  Among  the 
first  are  psychic  shock,  terror,  the  psychic  trauma,  sometimes  vith 
immediate  eifect.     The  psychosis  begins  with  its  cause. 

Gradually  sorrow,  care,  offended  ambition,  deceived  or  hope- 
less love  undermine  mental  health. 

Psycliic  infection,  also,  belongs  to  the  psychic  causes. 

An  insane  person  transfers  his  anxiet}',  his  delusions,  and  his 
hallucinations  to  another  predisposed  individual  who  has  been 
with  him  constantly,  has  ntirsed  him  and  taken  great  interest 
in  him. 

The  mental  disease  which  arises  in  the  second  individual  is 
called  induced  insanity  (folie  a  deux,  folie  communiquee)  .^ 
Usually  we  have  here  in  both  persons  an  equal  and  similar 
development  of  paranoic  states  with  a  religious  or  erotic  color- 
ing of  the  delusions,  sometimes  in  the  form  of  the  querulant  de- 
lusion. There  are  also  melancholic  forms,  especially  in  religious 
delusions,  where  quite  often  other  members  of  the  family  are 
infected,  so  that  folie  a  cinq,  folie  a  sept,  and  so  on,  are  observed. 

Many  epidemics  of  mental  disease  in  which  the  religious 
momenta  play  a  principal  part  are  to  be  regarded  as  induced 
psychoses,  especially  those  of  hysteric  nature  (delusion  of  witch- 
craft, resurrection). 

Induced  insanity  has  been  observed  in  twins  (folie  gemel- 
laire).-  One  must  distinguish  from  induced  insanity  in  twins 
those  cases  in  which  twins  contemporaneously,  btit  without  being 
in  direct  contact  with  each  other,  become  mentally  diseased  inde- 


'•  Sehonfeldt.  Archiv  fiir  Psyehiatrie.  1894,  xxvi.  Riedel.  Eulen- 
burg-'s  Vierteljahrschrift,  1897.  '^Mever.  Archiv  fiir  Psychiatrie,  1901, 
xxxiv. 

-Herfeldt.  Zeitschrift  fiir  Psvchiatrie,  vol.  57.  Soukhanoff  Ann. 
Med.  psvch.,  1900.  Sept.-Oct. 


Direct  Causes.  129 


pendently  of  each  other,  perhaps  at  different  places,  and  quite 
often  of  the  same  form  of  ps3''chosis. 

Induced  insanity  affects  women  especially.  The  mental 
disease  is  transferred  from  mother  to  daughter,  or  from  daugh- 
ter to  mother,  or,  very  frequently,  from  sister  to  sister.  Some- 
times one  sees  the  insanity  of  the  husband  transferred  to  the 
wife,  and  vice  versa. 

Quite  often  the  induced  person  is  not  only  predisposed,  but 
also  more  or  less  imbecile. 

Induced  insanity  must  be  distinguished  from  transformed 
insanity.^  Here  one  mentally  diseased  transfers  his  delusions 
to  another  insane  person,  and  modifies  thereby  the  typical  pic- 
ture of  the  latter  without  bringing  forth  any  considerable  change 
in  his  condition. 


2.  The  Somatic  Causes. 

(a)   The  trauma  (see  psychoses  by  trauma). 

(&)  Diseases  of  the  nervous  system.  So  far  as  hysteria, 
epilepsy,  and  chorea  are  considered  causes  of  psychoses,  they  will 
be  discussed  in  the  chapters  on  special  psychiatry. 

In  this  place  we  shall  only  accentuate  the  facts  that  neural- 
gias of  the  most  diverse  kind  may  call  forth  psychoses  in  the  pre- 
disposed by  their  severe  pain,  the  lack  of  rest  at  night,  indirectly 
by  the  narcotics  and  hypnotics  wdiich  are  used  to  relieve  them. 

In  similar  manner,  in  relatively  few  cases  severe  migraines 
lead  to  mental  disturbances.  Sometimes  a  state  of  mental  dis- 
turbance (obscurity  of  the  consciousness,  deliria,  hallucinations) 
appears  as  an  equivalent  or  as  a  posthemicranic  attack  corres- 
ponding to  the  observations  in  epilepsy. 

See  the  chapters  on  special  psychiatry  for  the  psychoses 
arising  in  consequence  of  organic  diseases  of  the  brain. 

(c)  Diseases  of  the  other  internal  organs.  TuhercuJosis, 
especially  tuberculosis  of  the  lungs,  sometimes  generates  mental 
disturbance,  as  a  rule  in  the  form  of  melancholia,  especially  in 
the  period  of  puberty. 

Often  during  the  psychosis  the  progress  of  the  lung  disease 


■  Finkelsteiii.    Jahrbuch  fiir  Psyehiatrie,  vol.  16. 

9 


130  Tlie  Etiology  of  Mental  Diseases. 

is  checked,  but  it  makes  more  rapid  advances  after  the  termina- 
tion of  the  psychosis. 

Organic  psj'choses  may  condition  tuberculosis  by  chronic 
meningitis,  solitary  tubercles,  and  tubercular  brain  abscesses. 

Cardiac  diseases,  with  the  predisposed,  sometimes  are  fol- 
lowed by  psychoses.^ 

The  psychoses  generally  follow  the  type  of  mania  or  of 
delirium  hallucinatorium,  seldom  as  melancholia. 

Diseases  of  the  gastro-enteric  tract.-  The  anamnesia  shows 
in  a  great  number  of  cases  of  mental  diseases  disturbances  of  the 
digestion,  generally  connected  with  constipation. 

In  no  small  number  of  cases  the  disturbance  is  conditioned 
by  an  affection  of  the  nervous  S3'stem.  This  is,  like  the  mental 
disease,  a  symptom  of  the  existing  affection  of  the  central  ner- 
vous system. 

In  other  cases  the  phenomena  conditioned  by  the  disturb- 
ances of  digestion  accelerate  the.  breaking  out  of  the  mental  dis- 
ease or  hasten  its  course. 

In  a  third  series  of  cases  intestinal  disturbances,  which  have 
arisen  independently  of  the  nervous  system,  act  physically  or 
chemically  in  the  generation  of  the  psychoses. 

The  replete  stomach,  the  distension  of  the  transverse  colon 
pushes  up  the  diaphragm,  inhibits  the  activity  of  the  heart,  calls 
forth  anxiet}',  fear  of  heart  disease,  apoplectic  attacks,  sleepless- 
ness, and  becomes  thereby  an  occasion  for  hypochondric  mental 
disease.  With  these  a  hyperacidity  or  a  h}^3oacidity  of  the  gas- 
tric juice  may  he  present ;  generally  there  are  belching,  borboryg- 
mus,  and  obstinate  obstruction  of  the  bowels. 

Through  chemical  agencies  the  poisons  generated  and  ab- 
sorbed in  the  intestine  lead  to  the  autointoxication  psychoses 
(which  see). 

Autointoxication  through  affections  of  the  liver  and  kidneys 
undoubtedly  plays  an  important  part  also  in  the  development  of 
mental  diseases. 

How  far  this  is  the  case  in  disease  of  the  female  sexual 
organs,  especially  of  the  ovaries,  must  remain  undecided;  more- 


^  Fischer.     Zeitschrift  fur  Psvchiatrie,  vol.  54,  p.  104S;     1898. 
-Herzog.     Archiv  fiir  rsychiatrie,  1899,  xxxi,  170. 


Direct  Causes.  131 


over,  these  organs,  as  in  hysteria,  have  lost  a  great  part  of  their 
etiological  significance  in  the  production  of  the  psychoses.^  Im- 
paired development  of  these  organs,  as  that  of  the  testicles  or 
the  penis,  or  hermaphroditism  in  man,  and  the  impotence  caused 
Ijy  them  may  lead  psychically  to  the  generation  of  psychosis  (gen- 
erally in  the  form  of  hypochondric  melancholia  or  paranoia). 
The  psychoses  called  forth  by  disease  of  the  thyroid  gland  will  be 
separately  treated.  The  same  is  true  of  the  mental  diseases 
generated 

(d)  By  infectious  diseases  and 

(e)  By  poisons  (alcohol,  morphine,  cocaine). 
There  remains  only  syphilis  to  be  considered. 
Syphilis  may  call  forth  mental  disease  when  :- 

1.  The  predisposed  infected  person,  on  account  of  the  in- 
fection, reproaches  his  manner  of  life  and  becomes  melancholy, 
or,  in  his  anxious  excitement,  is  afraid  of  all  the  horrors  of 
secondary  and  tertiary  syphilis  (hypochondric  melancholia 
with  syphilo phobia). 

2.  An  acute  infection  psychosis  is  generated  by  the  syphilitic 
poison,  generally  with  severe  headache  and  obscurity  of  the  con- 
sciousness, quite  often  with  contemporaneous  rise  of  temperature. 

3.  An  organic  S3q3hilitic  psychosis  arises  (which  see). 
Syphilophobia    is    often    observed,    also,    without    previous 

syphilis  in  hypochondric  states,  in  the  phobia  of  touch. 

Finally,  psychoses  sometimes  arise  through  long-continued 
or  frequently  repeated  tiresome  anti-syphilitic  cures. 


3.  The  Mixed  Causes — that  is,  Those  Acting  Psychically 
and  Somatically. 

Among  these  onanism,  sexual  excesses,  and  a  generally  dis- 
solute life  may  be  emphasized. 

War,  with  its  mentally  exhilarating  and  physically  debili- 
tating influences,  together  with  a  general  insufficiency  of  nutri- 
tion, also  belongs  here. 

The  same  is  also  true  of  those  ship wr eel- ed. 


^Hegar.     Zeitsclirift  fiir  Psyohiatrie.  1901,  Iviii,  357. 
-Jolly.     Klinisehe  Wochenschrift,  1901. 


132  The  Etiology  of  Mental  Diseases. 

A  large  percentage  of  mental  diseases  originate  in  prison} 
especially  among  those  isolated  and  condemned  to  solitary  con- 
finement. 

In  a  goodly  number  of  these  cases  it  concerns  men  who  were 
already  mentally  diseased  at  the  time  of  their  sentence,  and 
whose  mental  disease,  becoming  worse  under  the  injurious  in- 
fluences of  the  prison,  breaks  out  with  symptoms  which  are  clear 
even  for  laymen. 

Prison  psychoses  are  partly  acute;  they  run  their  course  with 
marked  hallucinations  of  hearing  and  of  touch,  like  delirium 
tremens  or  delirium  hallucinatorium,  or,  also,  under  the  type  of 
acute  hallucinatory  paranoia  (in  these  cases  regularly  with  delu- 
sions of  j)ersecution,  anxious  excitement,  seldom  as  melancholias 
or  hypochondric  melancholias),  partl}^  with  a  chronic  course 
like  simple  chronic  paranoia  or  hallucinatory  paranoia,  as  chronic 
alcoholism,  as  epileptic  mental  disturbances,  and  as  paresis. 

So  far  as  imjDrisonment  or  isolation  is  found  to  be  the  cause 
of  a  psychosis,  it  is  generally  soon  cured  by  release  or  by  com- 
mitment to  an  institution  for  the  insane. 

Eecently  we  have  had  in  Germany  psychoses  which  were 
called  forth  by  residence  in  the  tropics  (tropical  insanity).  This 
applies  also  to  the  American  soldiers  sent  to  the  Philippine 
Islands. 

The  question  is  here  of  physical  over-exertion,  mental  ex- 
citement, called  forth  by  the  constant  threatening  of  wild  people, 
malaria,  and  an  excessive  use,  especially  for  the  tropics,  of  alco- 
hol, nicotine,  even  of  tea,  often  contemporaneous  with  insuffi- 
cient nourishment. 

The  clinical  types  fall  under  those  of  delirium  hallucina- 
torium, acute  or  chronic  alcoholism,  seldom  under  those  of  mel- 
ancholia or  paranoia. 

In  many  of  these  patients  a  predisposition,  through  family 
inheritance,  can  be  shown. 

Some  authors,  finally,  have  considered  exhaustion  as  a  special 
etiological  factor  for  the  development  of  psychoses  and  have 
spoken  of  exhaustion  psychoses.^ 


^  Riidin.   Zeitschrift  fiir  Psyehiatrie,  1901,  Iviii,  447.   Niieke.   Unter- 
bringung  geisteskranker  Verbreeher.     Halle,  1902. 
-Racke,  Zeitschrift  fiir  Psyehiatrie,  1900,  Ivii. 


Outhreak,  Coarse,  and  Duration  of  J'sijckoses.  133 


That  exhaustion  or  inanition  may  generate  psychoses  is  not 

at  all  doubt  ['ill,  and  many  of  the  above-mentioned  psychoses  act 
singly  or  together  by  exluiustion. 

But  since  a  definite  clinical  type  of  exhaustion  psychoses 
is  lacking,  as  also  a  characteristic  anatomo-pathological  lesion, 
it  is  advisable,  then,  in  concrete  cases  to  refer  the  etiological 
designation  of  the  psychosis  to  that  factor  which  has  brought  on 
the  exhaustion. 


C.   The  Outbreak,  Course,  Duration,  Result 
of  Psychoses. 

The  outbreak  of  a  psychosis  may  be  acute,  following  its 
cause  immediately  or  almost  immediately. 

This  is  observed  in  traumata  of  the  head  or  in  psychic  trau- 
mata, as  a  consequence  of  epileptic  seizures,  in  the  most  diverse 
intoxications,  the  delirium  of  fever,  and  also  in  the  psychoses 
following  infectious  diseases. 

In  the  great  majority  of  cases  the  outbreak  is  gradual. 

Sleeplessness,  digestive  disturbances,  feeling  of  depression, 
change  of  the  temper  without  motive,  and  irritation  form  the 
transition  from  health  to  disease. 


COURSE  AND  DURATION  OF  PSYCHOSES. 

There  are  psychic  disturbances  which  run  their  course  in 
the  fraction  of  an  hour  or  in  a  few  hours;  these  are  desig- 
nated as 


1.  Transitory  Mental  Disturbances. 

These  may  rise : — 

1.  By  a  violent  emotion  in'hereditarily  predisposed  individ- 
uals or  imder  the  influence  of  great  bodily  pain  (e.g.,  trigeminal 


134  Outhreal-,  Course,  and  Duration  of  Psychoses. 

neuralgia),  under  the  combined  action  of  the  emotions  and  the 
j)ains  of  parturition,  mostly  with  greater  or  less  obscuring  of 
the  consciousness,  and  raving  excitement. 

2.  By  epilejjsy  and  hysteria  as  equivalents  or  as  pre-  or 
post-ei3ilc2itic  or  hysteric  insanity. 

The  majority  of  cases  which  have  been  described  as  mania 
iransitoria  were  epileptic  equivalents. 

3.  In  consequence  of  intoxications,  especially  frequent  from 
alcohol  (see  alcoholism),  also  from  carbon  dioxide  and  illum- 
inating gas. 

4.  In  organic  brain  diseases,  brain  tumors,  brain  apoplexies. 

5.  As  heightening  of  a  fever  delirium. 

6.  With  the  misconception  of  lasting  melancholic  states 
there  are  rapid  transitorj^  exacerbations  of  the  same  (raptus 
melancholicus)  which  are  nnderstood  as  mania. 

A  mania  of  such  short  duration  as  mania  transitoria  does  not 
exist. 


2.  Acute  Mental  Disturbances. 

Under  the  name  of  ^'delirium  acutum"  Brierre  de  Boismont 
first  d^cribed,  in  18-i5,  a  mental  disease  whose  symptoms  and 
course  appeared  in  the  following  manner :  After  a  short  pro- 
dromal stage  with  headaches  and  gastric  disturbances,  there 
suddenly  aj^peared,  and  generally  \ex\  violently,  a  delirium  with 
great  disturbance  of  the  consciousness,  whicli  was  at  first  more 
of  an  anxious  nature,  but  which  afterwards  became  absolutely 
incoherent,  with  interminable  talking.  The  taking  of  nourish- 
ment was  limited  to  the  minimum,  the  weight  of  the  body  rapidly 
dimiiushed,  the  dry  lips  and  the  tongue  were  covered  with  fuli- 
ginous fur;  speech  was  difficult,  jerky,  and  finally  unintelligible. 
General  trembling  of  the  muscles  followed  the  violent  motor  and 
raving  impulse;  finally,  clonic  and  tonic  spasms  appeared.  From 
the  commencement  the  pulse  was  generally  accelerated  (100  to 
110),  the  temperature  showed  a  continuous  fever  (100°-102°  F.). 
Towards  the  exitus  lethalis  the  temperature  rose  to  105°  F.  and 
over.     The  patient  died  in  mild  delirium  and  general  collapse. 

The  time  from  the  beginning  of  the  disease  to  the  end  was 
one  to  three  weeks.     Eecoverv  is  noticed  in  verv  few  cases. 


Acute  Mental  Disturbances.  135 


Acute  delirium  is  a  symptom-complex  which  may  appear 
under  very  different  conditions.^ 

1.  In  a  violent  course  of  paresis  (the  galloping  form). 

2.  In  the  most  diverse  organic  brain  diseases:  meningitis, 
acute  hemorrhagic  encephalitis. 

3.  In  certain  infectious  diseases  (puerperal  infections). 

4.  In  febrile  delirium  tremens. 

5.  In  insane  patients  who  have  become  septicemic  in  con- 
sequence of  wounds,  especiall}'  in  maniacal  raving. 

6.  By  an  autointoxication  whose  exact  conditions  have  so 
far  been  wholly  unknown. 

The  bacterial  findings  in  acute  delirium  (Bianchi  and  Piz- 
zino)  require  further  researches,  especialh'  in  regard  to  their 
specificity. 

The  hysteric  and  epileptic,  like  the  intoxication  psychoses, 
often  run  an  acute  course,  if  they  do  not  appear  transitorily. 

A  subacute  course  distinguishes  the  curable  functional 
psychoses. 

The  onset,  like  the  decline,  is  not,  as  a  rule,  a  regular  one, 
but  accompanied  with  numerous  exacerbations  and  remissions; 
that  is,  the  disease  does  not  progress  uninterruptedly  to  its  cli- 
max, but  poor  days  and  hours  interchange  with  good  ones,  and 
thus  the  improvement  continues,  after  the  crisis  of  the  disease 
is  passed,  with  numerous  variations,  before  complete  recovery  is 
eventually  reached. 

The  duration  of  such  subacute  psychoses  amounts  in  the 
average  from  eight  to  ten  months. 

The  above-mentioned  variations  may  lead,  in  the  course  of 
the  disease,  to  a  long  period  of  remission,  lasting  days  or  weeks, 
of  the  symptoms ;  there  may  even  be  transitorily  a  perfect  free- 
dom from  delusions,  an  intermission  with  complete  consciousness 
(delirium  hallucinatorium,  mania).  Such  a  one  often  appears 
if  the  disease  consists  of  two  phases,  melancholic  and  maniacal, 
while  a  remission  or  intermission  is  intercalated  between  them.- 


^  Binswanger  and  Berger.  Archiv  fiir  Psychiatrie,  1901,  sxxiv,  114. 
Carrier  and  Martin.     Revue  neurologique.  1901,  770. 

=  The  question  is  not  of  a  legal  "lucid  interval.'"  but  of  a  short 
transitory  remission  or  intennissinn  in  such  cases.  The  disease  continues, 
even  when  the  symptoms  do  not  show  themselves  externally  in  the  same 
wav. 


136  Outhreah,  Course,  and  Duration  of  Psychoses. 

3.  The  Chronic  Mental  Disturbances 

develop  from  the  acute  or  subacute  (secondary  chronic  psychoses) 
or  are  from  the  very  outset  of  a  chronic  nature,  as  idiotism, 
chronic  paranoia,  organic  mental  diseases. 

They  may  manifest  a  stationary  type  during  their  entire 
existence,  frequently  as  secondary  dementia;  they  may  change 
many  times  in  .their  appearance,  like  the  katatonic  forms ;  they 
may  go  on  progressively,  like  the  organic  mental  diseases,  espe- 
cially paresis. 


4.  The  Periodically  Progressive  Mental  Diseases 

manifest  themselves  :^ 

1.  As  periodical  mania. 

2.  As  periodical  melancholia. 

3.  As  periodical  delirium  hallucinatorium. 

4.  As  periodical  paranoia. 

5.  As  circular  psychosis  (see  the  chapters  on  special 
psychiatry) . 

Further,  certain  periodically-appearing  physiological  pro- 
cesses, like  mensturation,  and  somatic  diseases  running  periodical 
courses,  like  malaria,  condition  mental  diseases  also  appearing 
periodicalh'. 

In  the  so-called  menstrual  psychoses,-  which  general^  appear 
premenstrually,  seldom  j)ostmenstrually,  one  as  a  rule  deals 
with  hysteric,  hystero-epileptic,  or  epileptic  individuals,  in  whom 
menstruation,  often  also  dsymenorrhea,  gives  the  accidental 
cause  for  the  elaboration  of  a  chronic  nervous  disease  into  an 
acute  psychosis. 

Sometimes  these  periodical  disturbances  appear  in  girls  in 
whom  menstruation  is  disturbed  or  delayed  (psychosis  of  men- 
sintal  development,  Friedmann),  and  vanish  with  the  appear- 
ance or  regulation  of  the  menstruation;  as,  on  the  other  hand, 
cases  of  periodical  insanity  come  on  with  the.  menstrual  t}^e  in 
the  climacteric  after  the  disappearance  of  menstruation. 


^  Die  periodischen  Geistesstorungen.  Jena.   1901. 

-  Krafft-Ebing.     Psvchosis  menstrualis.     Stuttgart.   1902. 


Progressive  Menial  Diseases.  137 


The  form  of  menstrual  psychosis  varies  greatly,  it  is  as 
varied  as  the  type  of  the  hysteric  psychosis;  its  duration  extends, 
as  a  rule,  for  a  few  days,  but  sometimes  may  continue  for  weeks. 

Epileptic  psychoses  may  also  appear  periodically,  mostly 
with  very  great  confusion  and  abundant  hallucinations,  and, 
further,  certain  forms  of  alcoholism   (see  dipsomania). 

Eegarding  the  course  of  psychoses,  the  individual  mental 
balance,  the  general  physical  condition,  the  age  in  which  the 
psychosis  appears,  but  more  especially  a  considerable  hereditary 
taint,  are  of  special  importance. 

Heredity,  on  one  hand,  may  cause  the  disease  to  appear  not 
very  complex  by  the  innumerable  remissions  (often  in  paresis), 
or  by  the  imperfect  development  of  the  characteristic  s^anptoms 
of  the  type  of  the  psychosis.  On  the  other  hand,  one  sees,  espe- 
cially in  functional  psychoses,  that,  with  considerable  hereditary 
taint,  the  course  is  very  slow  and  that  symptoms  of  apparent 
mental  weakness  may  deceptively  show  incurability,  while  the 
further  course  results  in  recovery.  One  may  say,  in  general, 
that  a  considerable  hereditary  taint,  especially  in  functional 
psychoses,  blurs  the  typical  pictures. 

Formerly  a  great  and  favorable  influence  ujDon  chronic 
psychoses  of  some  duration  was  ascribed  to  the  first  appearance, 
as  well  as  to  the  cessation,  of  menstruation. 

The  course  anticipates  this  hope  only  very  exceptionally. 
The  first  appearance  of  menstruation  in  such  cases  is,  as  a  rule, 
without  any  importance  in  the  course  of  the  disease,  but  the 
climacteric  is  wont  to  make  existing  chronic  psychoses  worse,  to 
accelerate  the  weakening  of  the  mental  powers^  or  to  add  to  the 
existing  symptoms  new  hallucinations  and  delusions  belonging 
to  the  climacteric. 

In  acute  and  sul)acute  psychoses  the  appearance  of  men- 
struation is  generally  connected  with  great  excitement,  as  even 
normal  women  are  frequently  very  irritable  at  the  time  of  the 
menses. 

Febrile  diseases  which  appear  during  the  existence  of  the 
psychoses  sometimes  influence  the  course  of  the  mental  disease 
favorably.  Typhoid  fever  and  smallpox  should  be  especially 
mentioned  in  this  connection. 


138  Outbreak,  Course,  and  Duration  of  Psychoses. 

Alcoholism,  morphinism,  and  other  chronic  intoxications 
generally  make  the  course  more  difficult,  by  adding  their  own 
symptoms  to  those  of  the  psychosis  which  is  independent  of'  them. 


RESULTS  OF  THE  PSYCHOSES. 

1.  Recovery. 

The  recovery  of  a  person  mentally  diseased  may  take  place 
suddenly.  This  often  happens  with  ej^ileptics  and  alcoholists 
(delirium  tremens),  very  rarely  in  the  functional  curable  psy- 
choses, then,  as  a  rule,  in  individuals  heavily  tainted  hereditarily 
and  with  an  inclination  to  sudden  relapses. 

I  saw  a  melancholiac  recover  suddenly  after  the  first  injec- 
tion cf  morphine;  a  hj'pochondric  melancholiac,  immediately 
after  the  placing  of  a  pessar}^ 

The  recovery  may  follow  gradually  with  many  variations — 
the  usual  case — or  with  constant  gradual  diminution  of  the 
pathological  phenomena. 

The  duration  of  the  different  psychoses  until  recovery  will  be 
discussed  in  the  chapters  on  special  psychiatry.  "We  will  only 
remark  here  that  by  far  the  greater  number  of  recoveries  take 
place  in  the  first  year  of  the  disease,  and  that  after  two  years 
duration  recovery  can  be  considered  only  as  a  very  rare,  excep- 
tional result ;  however,  late  recoveries  may  take  place  after  three, 
even  after  twenty  years.^  These  late  recoveries  appear  chiefly  in 
depressive  mental  disturbances,  sometimes  during  the  climac- 
teric. 

The  recovery  often  takes  place  after  the  original  form  of 
disease  has  passed  into  another  form,  especially  after  a  melan- 
cholia has  ended  in  a  mania,  seldom  when  a  mania  has  ended  in 
a  melancholia  (manic-depressive  insanity). 

2.  Incomplete  recovery. 
Eecoveries  with  defects  (Neumann). 

Although  the  patient  externally  makes  a  thoroughly  normal 
impression  and  resumes  his  business  as  before,  there  remain. 


^  Kreuser.     Spatgenesungen  bei  Geisteskranklieiten.     Zeitschrift  fiir 
Psychiatrie,  1900,  Ivii,  771. 


Results  of  Psychoses.  139 


single  residuary  hallucinations  and  delusions  which  persist  for 
the  remainder  of  his  life,  or  may  form  the  nucleus  ol  insanity 
by  relapses.  Generally  in  recoveries  with  defects,  although  the 
delusions  and  sense  deceptions  have  disapj)eared  completely  after 
the  subacute  psychosis,  tlie  patient  is  not  the  same  person  he  was 
before;  he  has  not  acquired  fully  his  former  energy  and  applica- 
tion; he  does  not  fit  well  into  the  world  around  him;  a  certain 
insecurity  pervades  his  actions. 

3.  Incurabiliiy. 

The  incurability  of  a  psychosis  may  be  pri)nary,  as  in  the 
organic  psychoses,  idiocy,  chronic  paranoia ;  or  it  may  be  sec- 
ondary, when  a  primary  curable  psychosis  is  transformed  into 
secondary  mental  weakness — dementia  (terminal  dementia). 

The  degree  of  the  terminal  dementia  and  the  external  form 
in  which  it  appears  may  be  very  different,  and  in  these  one  may 
distinguish : — 

(a)   Secondary  'paranoia} 

A  form  of  mental  disturbance  proceeds  from  delirium  hal- 
lucinatorium,  mania,  or  melancholia,  which  is  distinguished  by 
paranoic  delusions,  but  shows  contemporaneously  a  strange 
mental  obliquity  of  primary  paranoia  in  its  first  stages. 

In  the  great  majority  of  cases  this  secondary  paranoia 
finally  becomes  complete  dementia. 

(&)   Acquired  imhecility. 

Delusions  and  sense  deceptions  are  not  present,  or  so  faded 
that  they  do  not  appear.     But  the  man  has  become  another. 

His  capability  of  forming  judgments  is  diminished,  criti- 
cism is  not  prompt  but  defective,  the  memory  is  generally  weak- 
ened, and  the  sense  of  propriety  has  not  its  former  power. 

With  the  diminished  capability  of  execution  is  connected 
a  diminished  capability  of  resistance  against  the  changes  of 
momentary  feelings  or  impulses  to  action.  Such  mentally  weak 
persons  may,  with  suitable  guidance  (but  not  without  this),  still 
work  very  well,  may  even  earn  their  livelihood. 

(c)   Agitated  dementia,  demented  confusion. 

Delusions  and  hallucinations  are  transposed  from  the  pri- 
mary psychosis,  but   they   are  weakened,   not   accompanied   by 


^  Mijnkmoller.    Zeitsclirift  fiir  Psychiatric,  1901,  vul.  Iviii,  p.  069. 


140  Outbreak,  Course,  and  Results  of  Psychoses. 

vivid  feelings  or  emotions.  They  are  no  longer  connected;  only 
single  words  point  to  them,  and  one  may  often  recognize  the 
preceding  functional  psychosis  of  confusion  by  the  frequent 
repetition  of  such  words  and  by  the  behavior  of  the  patient. 

The  former  melancholiac  stands  in  silence  and  bites  his 
finger  nails;  the  former  maniac  shows  himself  influenced  still, 
at  intervals,  by  raving;  the  quondam  paranoiac  is  querulous, 
snappish,  or  broods  gloomily.  Many  appear  with  all  kinds  of 
orders,  epaulettes,  in  peculiarl}'  grotesque  apparel. 

(d)  Apathetic  dementia. 

Mental  power  is  reduced  to  a  minimum,  only  a  vegetative 
life  exists  in  the  most  developed  form  of  this  dementia.  Mem- 
ory is  wanting;  only  harsh  sense  stimuli,  the  view  of  food  and 
drink,  are  still  accompanied  by  feelings. 

Finally,  there  follows  a  paralysis  of  motility  and  of  the  re- 
flexes. The  patient  must  be  waited  upon  like  a  child  in  its 
first  year. 

In  this  terminal  dementia  one  often  finds  dilated,  some- 
times very  mobile  pupils,  or  the  pupillary  reflex  sluggish  to  the 
impression  of  light.  The  tongue  often  trembles,  also  shows 
fibrillary  twitchings. 

The  power  of  the  extremities  is  generalh"  lessened,  often 
a  certain  hypotonia  of  the  articulations  exists.  The  tendon 
reflexes  are  generally  prompt. 

The  question  why  a  functional  psj'chosis  ends  in  recovery 
in  one  ease,  while  in  the  other  it  passes  into  incurable  dementia, 
cannot  be  answered  at  this  time. 

Experience  teaches  that  those  functional  psychoses  espe- 
cially those  appearing  in  the  age  of  puberty  and  in  which  there 
is  a  considerable  hereditary  taint,  frequently  and  quite  rapidly 
pass  into  dementia  (dementia  prajcox,  in  which  Krapelin  distin- 
guishes a  hebephrenic,  a  katatonic,  and  a  paranoic  form) . 

The  pathological  types,  just  described,  of  weakmindedness, 
of  agitated  dementia,  and  of  apathetic  idiocy  may  gradually 
develop,  one  from  the  other;  imbecility  may  pass  into  the  agi- 
tated form  of  dementia,  then  into  apathetic  idiocy.  But  any  one 
of  the  above-mentioned  forms — and  this  happens  in  the  ma- 
jority of  cases — may  develop  immediately  from  the  primary 
psychosis,  and  this  form  may  remain,  or  a  great  agitation,  if 


Results  of  Psyclioses.  141 


only  transitorily,  may  appear  in  the  imbeciles  or  those  apathetic- 
ally demented. 

Secondary  or  terminal  dementia  may  arise :  — 

(a)  From  a  functional  psychosis  (terminal  dementia  in 
the  narrower  sense) . 

(5)  From  epileptic,  hysteric,  or  choreic  psychosis  (neu- 
ropathic dementia). 

(c)   From  an  intoxication  psychosis  (toxic  dementia). 

4.  Deatli.^ 

This  may  be  conditioned : — 

1.  In  organic  psychoses,  by  apoplectic  and  epileptic  seiz- 
ures, by  paralysis  of  the  vagus  nerve  (paralysis  of  the  heart, 
hypostatic  pneumonia). 

2.  By  exhaustion,  whether  it  is  caused  by  high  continual 
fever,  or  by  scanty  or  insufficient  nourishment  (acute  delirium, 
melancholia.) 

3.  By  traumata,  whose  cause,  as  well  as  their  unfavorable 
course,  may  lie  in  the  psychosis  itself  (decubitus,  cystitis  after 
catheterization,  septicemia  in  consequence  of  injury,  gangrene). 
The  trauma  may  also  be  produced  by  an  accident,  as,  e.g.,  when 
the  bewildered  one  goes  through  a  v/indow  which  he  had  thought 
a  door,  Jumps  over  the  railing  of  a  bridge  into  the  river  because 
he  thinks  a  person  is  there  who  wishes  to  bar  his  way  (alcohol- 
ism, epilepsy).  In  epileptics  death  sometimes  ensues  by  suffo- 
cation from  the  position  of  the  body  during  the  seizure. 

4.  By  accidental  internal  diseases,  among  which  tuberculosis 
is  by  far  the  most  frequent;  yet  it  has  as  yet  not  been  proved 
that  pulmonary  tuberculosis  is  much  more  frequent  among  the 
insane  than  among  those  mentally  normal. 

5.  By  suicide.^ 

Attempts  at  suicide,  and  suicide,  may  take  place  among  the 
insane  in  very  different  ways : — 

(a)  Dissatisfaction  with  himself  and  the  world,  general 
pessimism,  or,  in  emotion,  from  motives  which  do  not  corre- 
spond to  the  enormity  of  the  deed  (in  inheritors,  in  imbeciles). 


^  Heimann.      Die    Todesursachen    der    Geisteskranken.      Zeitschrif  t 
fiir  Psyehiatrie,  1900,  Ivii. 

*K.ure.     Jahrbuch  fiir  Psyehiatrie,  1898,  p.  271. 


142  Outbreak^  Course^  and  Results  of  Psychoses. 

Here  also  belongs  a  considerable  number  of  the  suicides  in  eliil- 
dren,  who,  e.g.^  take  their  life  from  fear  of  punishment.  In 
chronic  alcoholists  the  consciousness  of  inferiority  and  the  in- 
capability of  saving  themselves  from  their  distress  often  lead  to 
suicide. 

(6)  RypocJiondn'c  delusions  quite  often  lead  to  suicide, 
thus  the  fear  of  insanity,  especially  the  fear  of  ''softening  of  the 
brain/'  of  severe  bodily  pain  (in  hypochondria,  in  hj^Dochon- 
dric  melancholia,  in  the  initial  stage  of  paresis,  in  rudimentary 
paranoia  in  which  the  torment  of  impellent  ideas  and  the  fear  of 
insanity  drives  to  suicide) .  Suicide  in  hypochondria  sexualis  is 
especially  frequent;  the  patient  is  afraid  of  becoming  impotent 
or  syphilitic,  or  both ;  a  secret  betrothal  or  the  wedding  drawing 
near  may  accelerate  the  carrying  out  of  the  suicidal  tendency. 

(c)  Suicide  takes  place  on  account  of  melancTioUc  deJu^ 
sions,  where  the  patients  think  that  they  have  lost  all  feeling 
for  their  friends  and  relatives,  even  the  joy  of  their  whole  life; 
from  this  they  think  they  are  useless  in  the  world,  or  that  they 
have  committed  some  crime  which  can  be  atoned  for  only  by 
death ;  that  they  can  avoid  the  disgrace  which  they  have  brought 
upon  their  families  and  the  punishments  which  they  expect,  only 
by  death. 

In  hypoehondric  nielanehoKa  sometimes  such  a  torment 
exists,  such  a  fear  of  death,  that  the  patient  prefers  death  itself 
to  the  permanent  torture. 

Finally,  on  the  basis  of  melancholia,  a  suddenly  heightened 
attack  of  anxiety  may  bring  on  suicide  (raptus  melancholicus). 
While  the  patient  is  delaying,  appears  entirely  uncertain,  a 
sudden  heightening  of  emotion,  vivid  hallucinations,  or  some 
external  cause  drives  him  to  the  deed. 

Grounded  on  a  melancholic  basis,  suicide  appears  in  mel- 
ancholia, in  the  depressive  phases  of  delirium  hallucinatorium, 
in  alcoholism,  in  paresis,  in  senile  dementia,  but  seldom  in  the 
circular  psychoses. 

(d)  From  jjaranoic  delusions  suicide  develops  in  the  fol- 
lowing manner : — 

The  patient  will  no  longer  bear  the  persecutions  from  which 
he  is  suffering,  or  he  wishes  to  burden  Ms  persecutors  with  a 
special  responsibility  for  his  death.     In  this  way  suicide  may 


Results  of  Psychoses.  143 


take  place  in  imbeciles,  in  paranoia,  in  paranoic  delusions  of 
paresis,  and  in  senile  dementia. 

{e)  MegaJo maniacal  ideas  may  be  the  cause  of  an  unpre- 
meditated suicide,  -u-hen  the  patient  wishes  to  show  that  he  can 
fly,  that  he  is  immortal,  and,  accordingly,  can  do  things  which 
endanger  his  life. 

(/)  Hallucinations,  especially  auditory  liallucinations,  may 
often  lead  to  suicide.  These  command  the  patient  to  destroy 
himself;  they  arise  on  a  melancholic  or  paranoic  basis.  One 
of  my  melancholic  patients  drowned  herself  because  in  her 
hallucinations  she  had  seen  her  husband  drown  and  heard  him 
call  for  help ;  she  wished  to  help  him. 

{g)  Ticiliglit  states,  in  which  the  memory  dwells  on  the 
concealed  ideas  of  suicide;  they  may  drive  to  accomplishment 
of  the  act,  with  want  of  consideration  (epilepsy,  alcoholism). 

The  manner  of  attempts  at  suicide  sometimes  allows  us  to 
recognize  the  tj'pe  of  the  insanity  underl3dng  the  action. 

The  melancholiac  is  distinguished  by  the  obstinacy  of  his 
attempts  at  self-destruction.  Sometimes  these  dominate  the 
type  of  the  disease  so  that  some  have  spoken  of  a  suicidal  mel- 
ancholia. The  violence  of  the  means  appears  quite  often.  A 
melancholiac  who  had  been  dismissed  from  the  asylum  uncured, 
crept  in  the  evening  into  an  oven  which  he  knew  would  be  heated 
in  the  morning  and  shot  himself  in  this  situation.  Others  set 
fire  to  their  beds  and  clothing,  which  they  have  previously  satu- 
rated with  petroleum.  Quite  often  the  mutilation  of  an  organ  or 
meml)or  is  connected  with  the  suicidal  attempt.  An  aged  melan- 
cholic clergyman  tried  to  destroy  himself  by  cutting  off  his  penis, 
with  which,  acccording  to  his  views,  he  had  transgressed  fifty 
years  before  by  onanism.  A  female  patient  first  stuck  her 
tongue  into  an  open  fire  because  she  had  blasphemed  God  with 
it,  then  cast  herself  into  the  fire.  A  young  man  cut  off  his  right 
hand  on  the  bank  of  a  river  (he  thought  he  had  committed  per- 
jury with  it),  then  he  drowned  himself. 

From  among  the  melancholiacs  are  generally  recruited  those 
suicides  who  first  kill  their  wives  and  children  to  preserve  them 
from  the  misery  of  the  world. 

Paranoiacs  commit  suicide  with  regard  to  all  external  cir- 
cumstances, like  a  coldly-considerate  healthy  person.    Hystericals 


144  Pathological  Anatomy  of  Mental  Diseases. 

frequently  threaten  self-destruction,  generally  on  account  of 
paranoic  ideas :  People  do  not  value  them  enough,  they  are  not 
helieved  to  be  sick.  The  attempt,  as  a  rule,  is  not  made  in 
earnest,  hut  one  must  not  reckon  too  much  that  it  will  not  suc- 
ceed. The  death  which  was  not  desired  ma}',  through  careless- 
ness in  the  suicidal  attempt,  really  occur. 

The  suicide  of  paretics  is  generally  distinguished  by  mental 
weakness,  by  the  lack  of  energy,  in  the  carrying  out  of  the  at- 
tempt, and  the  patient  stops  in  the  midst  of  the  execution.  One 
of  my  paretics  wished  to  poison  himself  l3y  carbon  dioxide,  but 
raised  the  window  because,  as  he  said  afterward,  he  feared  that 
the  Tapor  would  affect  his  lungs,  and  he  was  disposed  to  catarrh. 

Another  paretic,  who  wished  to  take  his  life,  took  off  his 
clothes  on  the  bank  of  a  river,  went  into  the  water  uj)  to  his 
knees,  but  then  returned  because  he  '^"liad  suffered  from  rheuma- 
tism, and  this  might  easily  come  back." 

Sometimes  the  insane  attempt  to  kill  themselves  by  refusing 
to  take  nourishment  (melancholia,  paranoia)  ;  sometimes  they 
place  or  force  foreign  objects  into  the  several  cavities  of  their 
own  bodies  (nose,  stomach,  bladder,  rectum,  vagina)  ;  or  they 
accuse  themselves  of  crimes  which  are  punishable  by  death,  and 
hope  to  be  executed  {indirect  suicide).  In  general,  insane 
women  have  a  greater  inclination  to  suicide  than  insane  men. 

In  many  families  self-murder  is  uncommonly  frequent ; 
sometimes  it  occurs  with  the  majority  of  the  members  of  the 
same  family  at  a  specified  age,  as  with  a  hereditary  disease. 

The  greatest  number  of  suicides  occur  in  smnmer,  especially 
in  the  month  of  June. 


D.   Pathological  Anatomy  of  Mental  Diseases. 

1.  A  series  of  psychoses  do  not  reveal  at  autopsy  any  patho- 
logical finding  along  any  definite  direction.  There  are  often 
conditions  present,  like  hyperemia,  anemia,  embolism,  or  throm- 
bosis, which  are  intimately  connected  with  the  cause  of  death  or 
with  the  agony,  but  not  with  the  psychosis. 


Diatjiiosis  of  Mcnliil  Diseases.  145 


2.  In  another  series  of  cases  macroscopic  changes  appear 
ill  the  memhrancs:  pachymeningitis,  tliickening  or  attenuation 
of  the  dnra,  hematoma  of  the  dura,  adhesion  of  the  dura  to  the 
calvarium  (present  in  about  50  per  cent,  of  all  cases  of  psychoses), 
pacchionian  graiuUatJous,  thickening  and  opacities,  also  milky 
turbidity  of  the  arachnoid,  especially  at  the  convexity  and  along 
the  sinus  longitudinalis  superior,  and  edema  of  the  arachnoid. 
But  these  are  as  little  characteristic  of  a  psychic  disease  as  the 
changes  in  the  nerve  cells,  which  singly  or  in  numbers  show  a 
disintegration  of  the  chromatic  substance   (chromatolysis). 

That  all  these  changes  do  not  prove  a  psychic  disease  which 
has  been  present  during  life  is  shown  by  the  same  or  similar 
changes  which  are  also  found  in  patients  who  never  had  a  psychic 
disease. 

3.  In  the  great  majority  of  cases  of  idiocy,  as  commonly  in 
organic  mental  diseases,  there  are  abnormalities  of  the  brain 
and  its  membranes,  which  will  be  more  exactly  described  under 
those  diseases. 

In  terminal  dementia,  there  is,  along  with  chronic  inflam- 
matory processes  of  the  meninges,  in  the  majority  of  cases,  a 
diminution  in  the  weight  of  the  brain,  averaging  200  grams, 
wdiereat  the  bulk  of  the  loss  in  weight  does  not  fall  upon  the  fron- 
tal lobes  of  the  brain,  as  in  paresis  (Parchappe  and  Bucknill). 
The  microscopic  examination,  generally,  but  not  constantly, 
shows  deposits  of  fat  and  pigment  in  the  ganglion  cells,  consider- 
able deposits  of  nuclei  in  the  vascular  walls,  and  dilatation  of  the 
capillaries,  which  are  usually  void  of  blood. 


E.   The  Diagnosis  of  Mental  Diseases. 

To  determine  whether  a  person  is  mentally  diseased  is  easy 
if  hallucinations  with  the  firm  belief  in  the  objective  reality  of 
the  hallucinated  sense  perceptions  are  produced,  or  if  the  delu- 
sions may  be  recognized  as  monstrous  by  their  content,  or  if  the 
characteristic  physical  symptoms,  as  in  paresis,  make  it  positive 


146  Diagnosis  of  Mental  Diseases. 

that  certain,  althongli  not  so  very  striking  s^tnjDtoms  of  ps}-cliic 
abnormalities  confirm  the  existence  of  a  mental  disease. 

Further,  the  thermometer  will  easily  distingiiish  the  deliria 
of  one  in  fever  from  the  garrulity  of  one  insane. 

The  diagnosis  may  be  doubtftil  and  difficult  -whether  the 
person  is  insane  or  not : — 

1.  In  imbeciles  (which  see). 

2.  In  secondary  states  of  mental  weakness. 

3.  In  dissimulation  of  the  sense  deceptions  and  delusions 
actually  present. 

If  there  is  an  anamnesia  sufficient  and  free  of  excuses,  the 
diagnosis  will  be  easy  if  one  presents  the  facts  of  the  anamnesia 
to  the  one  who  is  being  examined,  and  ascertains  from  his  be- 
havior towards  the  accusing  momenta  whether  the  symptoms 
which  seem  pathological  are  still  present. 

"Without  a  sufficient  and  reliable  anamnesia,  in  many  cases, 
an  observation  in  an  institution  or  oft-repeated  examinations 
cannot  be  avoided. 

For  the  diagnosis  of  the  special  forms  of  mental  disease, 
see  the  special  chapters. 

The  answer  to  the  cjuestion,  whether  any  one  who  has  been 
insane  may  be  regarded  as  eured,^  demands  the  following  con- 
siderations : — 

The  person  who  has  recovered  speaks  calmly  and  dispas- 
sionately of  his  disease,  although  he  may  seek  to  excuse  this  or 
that  in  his  behavior  during  the  existence  of  the  disease,  or  he 
describes  it  as  not  tmjustifiable  and  as  called  forth  by  certain 
actual  occurrences  in  his  surroundings.  His  former  aspirations 
have  returned,  his  demeanor  in  his  family  circle  shows  him  to 
be  himself  again. 

The  approach  of  recovery  is  generally  announced  by  the 
increase  of  the  body  weight  and  by  the  contemporaneous  dimi- 
nution of  the  pathological  psychic  s}Tnptoms. 

The  proof  that  the  patient  has  wholly  recovered  is  first 
evidenced  when  he  takes  up  and  fulfills  the  duties  of  his  former 
life  in  the  usual  manner. 


^  Heilbronner.       Kranklieitseinsiclit.      Zeitsclirift     fiir    Psveliiatrie, 
1901,  vol.  58. 


Diagnosis  of  Mental  Diseases.  147 


The  dictum  of  Willis,  that  "no  one  can  be  regarded  as  cured 
till  he  voluntarily  confesses  his  insanity,"  cannot  be  accepted 
in  this  categorical  form.  There  are  sporadic  cases  whicli,  in 
spite  of  a  limited  residual  insanity,  may  undoubtedly  be  consid- 
ered cured.  It  is  self-evident  in  this  respect  that  this  vestige 
of  abnormal  ideas  must  have  absolutely  no  influence  upon  the 
patient's  actions.  That  this  is  not  really  the  case  must  be  ascer- 
tained by  long  observation  of  the  person  in  a  free  condition  amid 
his  former  surroundings. 

Mental  disease  is  sometimes  simulated,  especially  to  aid 
litigation,  in  order  to  recover  damages  from  another  on  account 
of  an  injury  said  to  have  been  sustained  through  another's  negli- 
gence, to  have  a  marriage  declared  void,  as  a  criminal  defense, 
or  for  the  purpose  of  securing  release  from  confinement. 

The  forms  of  psychic  disturbances  which  are  especially 
studied  in  this  respect  are:  1,  raving;  2,  imbecility;  3,  stupor; 
4,  epileptic  insanity. 

Eaving  and  stupor  are  very  difficult  to  simulate.  The 
healthy  person  is  not  able  to  carry  on  violent  actions  as  long  as 
the  raving  maniac  without  cessation  and  without  food  and  drink, 
or  to  lie  for  days  and  nights  without  motion  like  one  in  stupor. 
The  symptoms  in  the  vascular  system,  the  peculiar  katatonic  or 
hypotonic  physical  symtoms,  are  also  absent  in  simulated  stupor. 
Perhaps  it  would  be  difficult  for  even  a  psychiatrist  to  simulate  a 
particular  type  of  psychic  disease ;  he  would  easily  commit  errors 
in  the  role.  A  simulated  epileptic  attack  would  be  recognized 
by  the  normal  behavior  of  the  pupils  and  the  fact  that  the  pre- 
tending patient  shows  no  spasms  in  the  masseters,  and  does  not 
bite  the  tongue,  the  absence  of  participation  of  the  muscles  of 
respiration  and  the  consequent  blueness  of  the  face. 

Imbecility  may  be  simulated  most  easily.  But  here  the 
exaggeration,^  the  incoherence  of  the  answers,  the  cunning  look. 


^  A  man  accused  of  fraud  asserted  that  he  did  not  know  his  age, 
the  year,  nor  how  to  covmt  money.  I  toolc  from  the  portemonnaie,  which 
he  had  handed  me,  a  mark;  he  said  that  he  did  not  know  how  much  it 
was,  then  I  showed  him  a  five-pfennig  piece  which  I  had  taken  from  my 
pocket-book,  but  he  would  not  recognize  this ;  I  then  put  it  in  his  porte- 
monnaie and  the  mark  in  mine  and  started  to  go  away  Avith  my  col- 
leagues. As  I  was  near  the  door,  he  called  to  me,  saying  that  I  had 
taken  a  double  amount  from  his  portemonnaie  and  put  into  mine.  He 
was  soon  forced  to  acknowledge  his  simulatiouj  as  I  was  able  to  secure 


148  Diagnosis  of  Mental  Diseases. 

and  the  expression  of  the  countenance,  betraying  the  effort  in 
simulation  as  ojDposed  to  the  vacant  expression  of  imbeciles,  will 
assure  the  diagnosis. 

With  this,  the  malingerer  is  generally  anxious  to  show  his 
pervertedness,  while  in  the  diseased  it  often  costs  much  trouble 
to  discover  the  delusions. 

Observations  by  good  attendants  will  generally  cast  aside 
every  doubt,  especially  when  it  can  be  shown  that  the  person, 
when  he  thinks  he  is  not  watched,  has  an  entirely  different  bear- 
ing than  at  the  time  of  observation,  or  of  medical  examination; 
that  he  sleeps  well,  eats,  drinks,  although  he  refuses  food  if  he 
thinks  that  he  is  observed. 

Sometimes  j)ieces  of  writing  whose  contents  are  diametric- 
ally opposed  to  his  assumed  demeanor,  betray  the  simulation. 

Simulation  of  insanity,  where  it  extends  over  a  considerable 
period  of  time,  weeks  or. months,  is  very  rare.  The  greater  the 
experience  of  the  physician,  the  more  rarely  will  he  have  occasion 
to  diagnose  simulation.  The  would-be  pretender  is  more  apt 
to  practice  dissimulation  in  the  presence  of  an  inexperienced 
practitioner. 

Insane  persons  often  simulate  certain  symptoms  ''in  fun," 
or  to  irritate  the  physicians  or  other  officials,  or  to  attain  a 
favorable  personal  advantage.  Since  these  insane  persons  have 
generally  a  certain  knowledge  of  psychiatry  which  they  have 
picked  up  in  the  asylum,  it  is  often  not  so  easy  to  recognize  th6 
simulated  symptoms. 

The  attempt  to  dissimulate  a  mental  disease  which  exists, 
is  undoubtedlv  more  common  than  that  of  simulating^  one  which 
does  not  exist;  in  the  majority  of  cases  it  is  with  the  object  of 
avoiding  a  threatened  or  obnoxious  guardianship  or  to  get  rid 
of  one  which  already  exists. 

But  such  dissimulations  appear  also  in  the  criminal  courts 
in  order  to  avoid  being  put  into  an  institution,  or  to  undergo  a 
punishment  limited  in  time,  since  confinement  in  the  institutions 
is  indeterminate. 

Gnauk's  patient,  who  was  punished  for  lese  majeste  and 


pieces  of  writing  from  his  desk,  written  in  the  last  few  days,  in  which 
he  had  written  exactly,  with  the  dates,  everything  which  he  had  re- 
ceived or  paid  out. 


Prognosis  of  Menial  Diseases.  149 


had  finished  his  term  of  punishment,  declared  afterwards  tliat 
he  had  said  nothing  to  the  judges  of  the  voices  which  liad  driven 
him  to  that  crime,  since  peo^jle  would  not  have  Ijclieved  him, 
and  if  they  had  believed  him  he  would  have  been  put  into  an 
institution  and  would  not  have  been  released  again.  Hence  he 
preferred  the  sentence. 


F.   The  Prognosis  of  Mental  Diseases. 

This  will  be  according  to  the  form  in  which  the  mental 
disease  appears.  It  is  unfavorable  in  idiocy,  in  organic  mental 
diseases  except  the  luetic,  in  the  chronic  forms  of  paranoia,  very 
doubtful  in  epileptic  psychoses,  especially  in  regard  to  relapses, 
and  in  some  of  the  intoxication  psychoses.  It  seems  to  be 
favorable  in  delirium  hallucinatorium,  mania,  melancholia,  acute 
dementia,  doubtful  in  acute  paranoia,  the  hysteric  psychoses, 
and  some  of  the  intoxication  psychoses.  The  prognosis  becomes 
more  unfavorable,  even  if  it  v^^as  favorable  previously,  if  the 
psychosis  has  lasted  a  year  without  definite  signs  of  improve- 
ment. 

In  all  cases  where  recovery  has  followed,  the  question  arises 
prognostically  whether  relapses  are  to  be  expected  or  whether 
the  disease  will  run  a  periodical  course. 

Eelapses  are  frequent  and  especially  to  be  feared  when  a 
considerable  hereditary  taint  gives  a  predisposing  influence. 
In  such  cases  a  new  insult  may  easily  bring  on  new  diseases. 

The  relapse,  which  may  appear  after  years,  even  decades, 
may  come  on  in  the  same  form  as  the  first  disease,  consequently 
a  melancholia,  mania,  a  delirium  hallucinatorium  may  appear 
in  the  second  attack  as  in  the  first,  sometimes  even  after  decades, 
with  exactly  the  same  delusions  and  sense  deceptions ;  in  other 
cases  the  second  attack  is  a  mania,  while  the  first  was  melan- 
cholia, or  inversely. 

The  relapses  have,  especially  in  inheritors,  a  less  favorable 


150  Prognosis  of  Mental  Diseases. 

prognosis  than  the  iDrimary  disease,  yet  even  here  there  may  be 
recovery  after  rei^eated  relapses. 

A  periodical  form  is  to  be  feared  if  the  primary  attack  ap- 
pears in  the  period  of  youth  of  one  strongly  tainted  hereditarily, 
especially  if  the  attack  runs  along  with  considerable  remissions 
and  is  speedily  cured. 

The  diagnosis  of  the  periodical  and  the  circular  form  can 
only  136  made  certain  by  the  course  of  the  disease. 

Further,  it  is  important  prognostically  to  declare  whether 
a  jDrimar}'  psychosis  after  a  certain  duration  will  pass  into 
terminal  dementia  or  not. 

If  the  affection  which  distinguished  the  primary  psychosis 
remits,  while  delusions  and  hallucinations  persist,  if  new  words 
are  formed  by  the  patient,  and  if  the  sleep  is  good  without 
improvement  of  the  psychic  s3'mptoms,  and  the  bodily  weight 
increases,  it  sjDeaks  strongly  for  a  transition  into  incurability. 

For  the  rest,  the  rule  adopted  in  practical  medicine  is  true 
in  psychiatry  even  to  a  greater  degree:  One  should  be  very 
careful  in  making  the  prognosis. 

The  coefficients  from  which  the  prognosis  is  formed  are 
much  more  uncertain  and  wavering  in  psychoses  than  in  any 
other  diseases,  and  we  know  that  prognoses  seemingly  thoroughly 
well  grounded  quite  often  miscarry. 


G.   General  Treatment.^ 

The  prophylaxis  of  psychoses  has  for  its  primary  object 
the  removal  of  the  most  important  and  most  frequent  cause  of 
mental  disease,  namely,  hereditarj^  predisposition,  by  preventing, 
above  all  things,  the  marriage-  of  persons  who  have  been  insane 


^  Emminghaiis.  Behandlung  des  Irreseins  im  Allgemeinen.  Hand- 
biich  der  specielle.  Pathologie  ii.  Therapie  von  Penzoldt  u.  Stintzing. 
Bd.  5.  1901 :  Pelman.  Ueber  die  Behandlung  der  Geisteskranken.  Deutsche 
KHnik,  1902. 

-Wm.  C.  Krauss,  Degeneracv.  Buffalo  Medical  Journal.  November, 
1898. 


Treatment  of  Menial  Diseases.  151 


or  are  alcoholists,  morphinists,  epileptics,  or  sufHering  from 
other  hereditary  nervous  diseases  or  their  equivalents. 

The  impossibility  of  acting  by  legislation  admonishes  us 
to  accomplish  as  much  as  possible  by  precept. 

It  is  very  important  to  keep  children  hereditarily  tainted 
in  other  society  than  that  of  a  nervous  or  insane  father  and  a 
nervous  or  insane  mother,  to  place  them  in  proper  homes  in 
order  to  paralyze  the  injurious  influences  of  being  brought  up 
by  their  parents  or  imitating  them.  In  Prussia,  the  carrying 
out  of  the  law  of  July  2,  1900,  relating  to  the  bringing  up  of 
minors  and  those  without  means,  provides  such  protection  under 
certain  conditions. 

Care  must  be  taken  in  the  choice  of  a  calling  in  regard  to 
the  peculiarities  of  those  tainted  hereditarily,  and,  as  a  rule, 
those  occupations  should  not  be  advised  which  demand  stren- 
uous mental  exertion  or  much  exercise  of  the  judgment. 

The  prophylaxis  of  mental  diseases  consists  also  in  the 
warfare  against  alcoholism  and  the  spread  of  syphilis,  in  the 
improvement  of  the  nutrition  of  the  people,  and  the  carrying 
out  of  tenement-house  reform. 

That  the  advancements  made  in  general  hygiene  may  attain 
great  success  in  this  direction  is  shown  by  the  diminution  of 
cretinism  in  Germany  since  the  betterment  of  the  hygienic 
conditions  in  certain  localities,  and  the  use  of  pure  drinking 
water. 

The  first  question  for  the  physician,  after  ascertaining  that 
a  mental  disease  exists,  will  be  whether  treatment  and  care  in 
an  institution  are  demanded,  or  whether  the  patient  can  remain 
at  home. 

Entrance  to  an  institution  will  be  necessary: — 

1.  If  the  patient  is  raving. 

The  inconveniences  of  a  private  house,  the  lack  of  the 
necessary  skilled  attendants  for  restraining  the  patient,  the 
proper  regard  for  the  other  persons  of  the  dwelling  call  for  the 
removal  of  the  patient.  An  exception  can  only  be  made  when 
the  form  of  the  raving  gives  hope  of  a  speedy  termination,  and 
supervision  at  home  is  then  possible  for  a  short  time. 

To  these  exceptions  belong  many  cases  of  post-epileptic 


152  Treatment  of  Mental  Diseases. 

raving,  epileptic  equivalents,  hysteric  ra%nug,   and  raving  fol- 
lowing intoxication. 

2.  If  the  patient,  without  ra\-ing,  when  at  libert}',  is  dan- 
gerous to  himself  or  to  others. 

In  this  class  belong. all  those  cases  where  suicide  is  to  be 
feared,  whether  the  patient  has  threatened  or  already  made 
such  attempts,  or  if  the  attempt  is  to  be  anticipated  from  the 
type  of  the  mental  disease.  Especially  is  this  of  great  import- 
ance in  melancholia.  Every  melancholiac  thinks  of  suicide,  and 
the  physician  ia  each  case  should  make  it  understood  that  he 
will  not  be  responsible  in  this  respect  if  the  patient  remains 
at  home.  Eor  like  reason  such  patients  should  not  be  sent  to 
sanitariums  unless  they  can  be  carefully  guarded. 

Similarly,  the  melancholic  states  of  other  psychoses  are  to  be 
considered  in  reference  to  the  tendency  to  suicide  (alcoholism, 
paresis,  senile  dementia). 

The  patient  may  also  be  dangerous  to  himself  and  to  his 
family,  if  he  dissipates  his  property,  makes  foolish  pecuniary 
obligations  for  the  future;  contracts  marriage,  or  makes  a  testa- 
ment or  changes  one  already  made. 

For  these  reasons  patients  who  suffer  from  expansive  delu- 
sions, delusions  of  grandeur  (maniacal,  periodically  maniacal, 
maniacal  paretics),  should  be  confined. 

Danger  for  others  may  proceed  from  ideas  of  persecution 
with  or  without  sense  deceptions.  The  hallueinators  are  spe- 
cially dangerous. 

Hallucinated  paranoiacs,  epileptics,  and  alcoholists  should 
be  sent  to  an  institution  in  every  case. 

Only  when  a  considerable  mental  weakness  prevents  the 
transition  of  the  hallucinated  sensorial  excitement  into  action, 
or  makes  it  very  improbable,  should  the  commitment  to  an  in- 
stitution be  changed  for  constant  supervision  at  home. 

But  without  hallucinations,  a  system  of  insanity  may  be 
dangerous,  especially  that  of  persecution,  before  the  mental 
weakness  has  yet  appeared  (paranoiacs,  alcoholists,  querulants). 

Finally,  there  are  persons  of  weak  mind,  who  do  not  have 
delusions  nor  sense  deceptions,  but  require  detention  on  account 
of  their  indecent  actions. 

3.  Sitophohic  patients  should  be  sent  to  an  institution,  since 


TrcaLiiient  of  Mental  Diseases.  153 


only  there  cau  they  find  the  necessary  supervision  and  treatment, 

4.  AVitliout  the  factors  above  mentioned,  it  may  be  neces- 
sary to  send  the  patient  to  an  institution  when  his  social  condi- 
tion does  not  permit  of  cave  and  attention  at  home. 

5.  The  cure  of  a  patient  demands  his  being  committed  to 
an  institution  in  order  to  Ivcep  him  thoroughly  quiet,  to  with- 
draw him  from  the  momentary  injurious  influences  of  his  for- 
mer environment,  to  prevent  him  from  encouraging  and  aggra- 
vating his  disease  through  excesses  and  debauchery,  and 
finally  to  give  him  the  opportunity  for  a  suitable  treatment, 
which  would  not  be  possible  at  home. 

In  exceptionally  favorable  conditions  a  villa  or  outlying 
cottage  may  afford  all  the  conveniences  of  an  institution. 

If  commitment  to  an  institution  has  been  decided  upon, 
it  should  be  done  as  soon  as  possible.  In  many  cases  the 
patient  thinks,  if  nothing  has  been  told  him,  that  something 
extraordinary  is  going  on,  perhaps  that  he  is  to  be  "taken  to  an 
insane  asylum,"  and  accordingly  he  tries  to  escape  or  commits 
suicide.  This  is  especially  the  case  with  melancholiacs  and 
paranoiacs. 

Before  his  transference  one  should  tell  the  patient  openly 
that  he  is  to  be  taken  to  a  hospital  and  have  the  necessary  force 
ready  to  subdue  any  possible  resistance.  With  few  exceptions 
the  patient  yields,  sometimes  only  when  he  has  seen  the  superi- 
ority of  force  against  him.  But  even  if  he  does  not  yield  it  is 
better  for  him  if  force  be  used  than  to  abstain  and  keep  him  in 
constant  excitement  and  fear  of  another  ordeal. 

Exceptionally,  in  order  to  avoid  a  crowd  running  to  the 
house  on  account  of  the  screams  of  the  patient,  stratagem  may 
be  used  in  which  the  officials  of  the  institution  to  which  the 
patient  is  to  be  removed  must  take  no  part.  The  employment  of 
narcotics  in  order  to  convey  him  to  the  institution  is  to  be 
discouraged. 

The  treatment  should  first  endeavor  to  reach  the  causal 
indication. 

This  will  be  discussed  in  the  chapters  on  Special  Psychia- 
try; it  demands,  above  all,  an  exact  anamnesia  with  the  most 
careful  physicial  examination. 

Just  here  it  may  be  mentioned  that  the  remedies  which 


154  TreatDiciit  of  Mental  Diseases. 

have  acted  favorably  in  a  definite  causal  indication  are  often 
used  without  such  indications,  but  simply  from  an  empirical 
standpoint.  Thus  the  thyroid  preparations  furnish  an  example, 
whose  wonderful  effects  in  m3^xedema  will  be  discussed  later.  A 
critical  analysis  of  the  results  gained  by  the  use  of  this  remedy 
in  no /i-myxedematous  ps5^choses  does  not  encourage  further  ex- 
periments along  this  line.^ 

Symptomatically  the  following  conditions  which  appear  in 
the  most  varied  psychoses  may  be  treated  as  follows: — 

1.  Anxiety  and  unrest.  Against  these  we  employ  the  bro- 
mide preparations,  several  times  daily  at  1,  1.5  to  2  grams,  also 
in  connection  with  aqua  lauroc.  and  extr.  hyoscyam.  (solut.  natr. 
bromat.  [12  to  18]  150.0,  aqua  lauroc.  6.0,  extr.  hyoscyam.  1.0, 
syr.  simpl.  30.0,  a  tablespoonful  three  times  daily). 

Antipyrin  0.5  to  1.0,  two  to  three  times  daily;  phenacetin 
0.5,  two  to  three  times  daily,  both  eventually  with  codein. 
phosphor.  0.03  to  0.05. 

Trional  in  small  doses,  three  to  four  times  daily,  0,5  g. 
may  also  be  tried. 

By  far  the  most  effective  is  opium  (either  crude  or  as  extr. 
opii,  or  in  doses  of  0.05  morning  and  noon,  0.10  evenings,  if 
necessary;  increasing  to  0.10  morning  and  noon,  0.15  [ !]  even- 
ings, as  tinct.  opii  simplex  at  10,  15,  20,  or  25  [ !]  drops).  See 
also  treatment  of  melancholia. 

It  is  necessary  to  watch  carefully  the  condition  of  the 
heart.  Intestinal  obstruction  is  to  be  combatted  by  the  use  of 
fruit,  by  saline  laxatives,  or  by  tea  from  Cortex  rhamni 
frangulae. 

In  many  cases  where  opium  brings  no  rest,  one  may  obtain 
it  by  morphine,  best  in  subcutaneous  injections  (0.01  to  0.015). 
It  is  not  necessary  to  fear  that  morphinism  will  proceed  from 
this;  under  medical  direction  the  habit  which  may  be  formed 
may  be  cured  before  the  termination  of  the  disease. 

The  addition  of  small  doses  of  scopolaminum  hydrobrom- 
icum  (0.0002  to  0.0003)  with  morphine  may  be  used.  Where 
vomiting  appears  after  injections  of  morphine,  one  should  add 
small  doses  of  atropin  (0.0001  to  0.0002). 


^Pilcz.     Jahrbueh  fiir  Psychiatric,  1901,  page  92. 


Treatment  of  Mental  Diseases.  155 

Rest  in  bed  (clinotherapy)  (Guislain,  Neisser)  also  acts 
as  a  sedative;  this  is  to  be  recommended  for  all  anemic  and 
badly-nourished  persons,  and  is  now  almost  universally  used 
in  acute  psychoses.  Clinotherapy  acts  favorably  on  the  circu- 
lation (the  acceleration  of  the  pulse  diminishes),  the  respiration 
becomes  slower,  and  it  favors  the  increase  in  weight,  or  rather 
inhibits  the  decrease  of  weight. 

It  is  to  be  used  carefully  where  onanism  exists,  and  besides 
hypochondric  conditions  demand  that  the  rest  should  be  inter- 
rupted quite  often.  If  too  long  continued  it  makes  the  patient 
apathetic  and  listless.  Clinotherapy  cannot  be  employed  where 
the  patient  acts  foolishly  in  bed,  turns  somersaults,  and  the  like. 

Wet  pads  also  act  as  sedatives.  The  entire  body  may  be 
wrapped  in  sheets  previously  moistened  in  water  of  from  85° 
to  93°  P.,  and  afterwards  covered  with  a  woolen  blanket.  The 
patient  lies  thus  for  one  to  two  hours.  This  procedure  may  be 
renewed  several  times  a  day. 

Finally,  protracted  baths  of  uniform  temperature  of  85° 
to  95°  F.  may  be  used,  with  cold  compresses  on  the  head. 

2.  Insomnia.  Even  if  a  constant  insomnia  injures  the 
patient  and  makes  the  intervention  of  medical  aid  necessary, 
it  is  also  essential  to  warn  against  the  too  frequent  employment 
of  hypnotics,  which  are  not  indifferent  for  the  condition  and 
the  general  nutrition  of  the  patient. 

In  any  case  one  should  try  to  induce  sleep  by  the  above- 
mentioned  means;  besides  the  full  baths,  in  the  evening,  sitz 
baths  of  half  an  hour  long  at  95°  F.,  putting  on  damp  stockings, 
wet  cloths  on  the  body,  massage  an  hour  l^efore  bedtime, 
all  these  should  be  used  before  prescribing  hypnotics.  The  last 
should  not  be  employed  every  night. 

We  may  consider  as  hypnotics : — 

Morphine,  subcutaneously,  0.02  to  0.03. 

Dionin,  0.01  to  0.015,  likewise  heroin,  0.01  to  0.02  subcu- 
taneously. 

Sulphonal,  1  to  2  g.,  best  administered  in  some  warm  liquid 
as  milk  or  water. 

(Symptoms  of  poisoning  after  sulphonal  appear  in  the 
urine  as  diminution  of  the  quantity  with  red  coloring,  which  is 


156  Treatment  of  Mental  Diseases. 

conditioned  b}'  hematoporphyrin.  The  red  nrine  becomes  dark 
after  standing.) 

Trional  and  tetronal,  1  to  2  g. ;  hedonal,  1.5  to  2.5  g. ; 
uretha?ie,  2  g. ;  amylhydrate,  3  to  4  g.  in  capsules  or  as  clysters 
with  mucilaginous  gum  Arabic. 

Paraldehyde  (5  to  8  g.)  gives  the  expired  breath  an  ofEen- 
sive  odor,  and  is  refused  by  man}'  patients  for  this  reason;  it 
is  to  be  given  with  sugar-water  or  raspberry  essence  (to  be 
avoided  in  all  irritations  of  the  mucous  membranes  of  the 
stomach  and  of  the  respiratory  apparatus).  In  enemata  it 
may  be  given  as  an  oleaginous  emulsion. 

In  alcoholic  ps3'choses  (especially  in  delirium  tremens)  and 
with  those  maniacalty  raving,  chloral  hydrate  is  active  where 
the  above-mentioned  remedies  fail.  Dose  3  to  4  g.  in  solution 
with  syr.  aurant.  cort.,  eventually  also  in  ch'sma.  With  the 
use  of  even  a  small  quantity  of  alcoholic  drinks  along  with 
chloral  hydrate,  a  rash  often  appears  (redness  of  the  entire  body, 
especially''  of  the  upper  part),  which  generally  disappears  after 
twenty-four  hours.     Care  is  advised  in  heart  diseases. 

Finally,  in  very  great  unrest  and  where  no  remedy  can 
be  given  the  patient  per  os  or  per  anum,  one  may  inject  sub- 
cutaneously  scopolamin.  hydrobromin.  0.0005  to  0.001;  or  du- 
boisin,  0.0008  to  0.001  to  0.0015.  After  five  or  ten  minutes, 
rest  general!}'  ensues,  but  which  as  a  rule  lasts  only  a  few  hours. 
A  long-continued  employment  of  this  remedy  is  not  advisable, 
since  it  acts  very  injuriously  upon  the  nutrition,  and  the  patients 
easily  collapse. 

In  many  cases,  all  these  remedies  prove  inefficient;  one 
should  not  increase  the  dose  then,  since  there  is  danger  of  call- 
ing forth  symptoms  of  collapse  in  passing  a  certain  limit.  Some- 
times the  patient  sleeps  better  without  a  hypnotic  than  with 
one. 

In  very  emaciated  persons,  in  psychoses,  after  acute  infec- 
tion psychoses,  in  delirium  hallucinatorium,  a  glass  of  beer  or 
ale,  several  glasses  of  heavy  wine,  or  an  egg  punch  acts  better 
than  h}'pnotics. 

3.  Refusal  of  nourishment.  In  patients  who  refuse  food 
one  should  never  neglect  to  leave  on  their  night-table  a  cup  of 
milk  or  bouillon,  some  cakes  or  roUs.     It  often  happens  that 


Treatment  of  Mental  Diseases.  157 

they  take  these  when  they  think  themselves  unobserved,  al- 
though they  have  just  refused  nourishment. 

But  if  the  patient  does  not  take  food  in  this  manner  and 
it  is  not  possible  to  feed  him  with  a  spoon  or  cup  (beaked  cup), 
one  must  give  the  food  by  the  esophageal  sound. 

Sometimes  even  the  threat  of  this  sort  of  feeding,  or  the 
preparation  for  it,  moves  the  patient  to  take  food  voluntarily. 

According  to  the  strength  of  the  patient,  one  may  wait  in 
absolute  abstinence  three  to  four  days  after  the  last  food  was 
taken ;  if  there  is  the  chloroform-like  aceton  odor  in  the  expired 
air,  one  should  not  delay  in  the  use  of  the  esophageal  sound. 

Whether  the  patient  lies  in  the  recumbent  position  with 
moderately  raised  head  or  sits  on  a  chair,  the  tube  is  slowly 
introduced  by  the  lower  nasal  passage,  or,  if  it  does  not  pass,  by 
the  mouth,  with  the  aid  of  Heister's  speculum. 

One  then  gives  daily  two  portions  of  milk,  1500  cubic 
centimeters,  300  grams  sugar,  six  eggs  with  water,  and  one  glass 
of  wine. 

ISTot  more  than  one  liter  of  liquid  nourishment  should  be 
given  at  one  time. 

One  may  add  nutritive  enemata  to  the  feeding  by  the 
stomach  tube.  Eventually  there  may  precede  in  suitable  cases: 
first  a  cleansing  clyster,  then  an  opium  suppository  (extr.  opii, 
0.05  to  0.075),  and  after  about  fifteen  minutes  Leube's  pancreas 
meat  clyster  or  Ewald's  egg  clyster,  or,  according  to  Eiegel,  300 
grams  milk,  1  glass  red  wine,  2  eggs,  some  common  salt,  or, 
according  to  Ziehen,  i/o  liter  water,  2  eggs,  2  tablespoons  of 
starch,  and  a  pinch  of  common  salt. 

Since  the  patient  very  often  expels  the  clyster  soon  after 
its  introduction,  this  mode  of  feeding  may  prove  ineffectual. 

One  should  combat  collapse  which  is  to  be  feared  or  has 
appeared  from  lack  of  nourishment,  by  infusions  of  common  salt. 

One  may  take  as  most  suitable  9  grams  of  common  salt  to  1 
liter  of  boiled  water;  warm  the  liquid  to  105°  F.,  and  inject  sev- 
eral times  daily  to  the  amount  of  200  cubic  centimeters.  The 
syringe  should  be  previously  boiled. 

4.  Against  weakness  and  collapse,  besides  the  common  salt 
infusions  just  mentioned,  caifeino-natrium  salicylicum  (contains 
63.5  per  cent,  caffein),  one  or  two  injections  of  a  20  per  cent. 


158  Treatment  of  Mental  Diseases. 

solution,  is  recommended;  subcutaneous  injections  of  etlier  (at 
the  back  or  breast,  not  in  the  extremities  on  account  of  bringing 
on  paral3'sis),  or  subcutaneous  injections  of  ol.  camphoratuin  in 
doses  of  a  Pravaz  S3'ringe,  repeated  as  needed. 

5.  Against  the  patient  soiling  himself  with  urine  and  feces 
and  smearing  liimself  with  the  stools,  besides  constant  watching 
and  frequent  taking  to  the  closet,  regulation  of  the  diet  in  a 
suitable  way,  so  that  the  nutrient  media  favoring  diuresis  and 
liquid  nourishment  generally  may  be  limited,  and  by  giving 
food  which  forms  little  fecal  matter,  should  be  employed. 

One  should  wash  out  the  rectum  several  times  during  the 
day  to  prevent  the  patient  removing  the  feces  and  smearing 
himself  therewith. 

6.  When  all  other  means  fail  to  pacify  the  patient  in 
maniacal  rage  for  destruction,  isolation  in  a  dark  padded  room 
is  necessary. 

This  isolation  is  preferable  to  the  attendants  holding  the 
patient  and  the  strife  which  generally  follows. 

The  use  of  mechanical  means  of  compulsion  (straight 
jackets,  binding  the  hands,  tying  the  feet  together,)  is  only 
permitted  when  certain  injuries  or  the  bandages  made  for  their 
cure  demand  the  absolute  rest  of  the  patient. 

7.  Against  suicide  the  only  protection  is  the  continual 
watching  of  the  patient.  Patients  suspected  of  suicidal  intent 
should  not  be  left  unwatched  for  a  moment,  day  or  night. 

8.  Decubitus  may  generally  be  avoided  by  scrupulous  clean- 
liness, foldless  bedclothes,  and  water  cushions,  but  not  always 
(decul)itus  acutissinms) . 

If  it  appears,  one  should  use  zinc  ointment,  lanolin,  borated 
vaseline  (10  per  cent.)  ;  to  give  free  drainage  to  gangrenous 
sanies;  lax  granulations  should  be  treated  by  acetated  clay,  wine 
of  ehamphor,  or  alcohol  (20  per  cent.).  After  spraying,  one 
should  carefully  dry  the  surrounding  skin. 

The  nourishment  of  the  insane,  unless  special  indications 
determine  otherwise  {e.g.,  diabetes,  anemia),  should  consist  of  a 
mixed  diet  in  which  fruit  and  milk  particularly  should  be  freely 
given. 

Alcoholic  drinks  should  be  given  only  in  response  to  special 
indications. 


Treaiment  of  Mental  Diseases.  159 

The  physician  must  approach  the  insane  person  with  earn- 
estness permeated  by  mildness. 

He  should  avoid  threats  and  joking  at  the  delusions  or  the 
appearance  of  the  patient.  In  the  presence  of  the  patient  he 
should  not  speak  of  the  prognosis,  which  is  perhaps  unfavorable, 
any  more  than  he  would  in  the  presence  of  a  normal  person,  nor 
of  things  generally  which  might  wound  the  patient  in  his  normal 
condition.  Just  as  little  should  the  physician  take  up  the  com- 
pletely useless  task  of  attempting  to  reason  the  patient  out  of 
his  hallucinations  or  delusions  (reasonable  grounds  disturb 
him),  but  he  should  not  concede  that  they  have  any  foimdation 
or  that  there  is  a  possibility  of  such  a  basis. 

If  he  does  not  prefer  to  let  the  patient  talk  without  answer- 
ing him,  he  will  best  repeat  continually,  "that  is  the  product  of 
a  pathologically  excited  fancy." 

As  soon  as  possible  the  patient  should  be  occupied  with 
gardening,  sawing  wood,  solving  puzzles,  and  the  women  with 
the  work  to  which  they  are  accustomed. 

For  the  chronically  insane,  colonization  for  agriculture,  by 
which  Paetz  has  rendered  great  service  in  Germany,  has  suc- 
ceeded very  well. 


PART    II. 

Special  Psychiatry. 


Up  to  this  time  there  has  been  no  success  whatever  in  ar- 
ranging the  different  forms  of  ps3'choses  under  one  system  or 
classification.  But  those  mental  diseases,  which  rest  on  a  de- 
fective development  of  the  brain — idiotism — and  those  which 
arise  in  later  life  and  show  a  visible  organic  change  of  the  brain 
— organic  psychoses — may  be  distinguished  without  difficulty. 

It  would  indeed  be  questionable  to  group  under  the  intox- 
ication psychoses  J  those  which  owe  their  origin  to  special  toxins, 
and  as  psychoses  conditioned  hy  central  neuroses  those  developing 
from  epilepsy,  hysteria,  or  chorea. 

On  the  other  hand,  there  is  a  great  difference  of  opinion 
among  authors  how  to  divide  those  mental  diseases  in  which  no 
anatomical  findings  have  hitherto  been  met  and  which  do  not 
belong  under  any  of  the  forms  named.  They  are  designated 
as  functional  psychoses,  by  which  it  is  not  said  that  anatomical 
changes  do  not  exist,  but  only  that  we  have  so  far  been  unable 
to  verify  them.     ■ 

If  in  this  respect  they  resemble  the  functional  peripheral 
neuroses,  it  seems  best,  in  want  of  a  better  arrangement,  to  as- 
sociate them  with  the  neuroses,  and  to  distinguish'  between 
h}']oeresthesia  and  neuralgia,  kinesthesia  and  paralysis,  and  to 
designate  hyperesthesia  as  melancholia,  kinesthesia  as  mania, 
and  the  paralyses  as  dementia.  Paranoia  is  to  be  designated  as 
an  atactic  mental  disturbance,  that  is.  as  a  mental  difficulty  in 
which  the  disturbance  of  the  coordination  of  ideas  is  primary. 
(With  this  the  crude  power,  that  is,  the  intelligence,  may  remain 
undisturbed,  especially  at  first.)  Finally,  that  form  in  which 
the  hallucinations  are  primary  and  essential  and  appear  with  a 
considerable  clouding  of  the  consciousness,  is  characterized  as 
delirium  hallucinatorium. 
(160) 


Idiotism.  161 

I.  IDI0TISM.1 

We  include  under  idiotism  those  states  of  mental  weakness 
and  paralysis  which  are  conditioned  by  an  inhibition  to  the 
development  of  the  brain. 

If  the  mental  weakness  is  present  only  in  a  certain  low 
degree,  we  speak  of  imbecility.  But  if  it  is  more  pronounced 
or  if  there  has  been  no  mental  development,  we  call  the  condi- 
tion idiocy. 

1.  Imbecility. 

According  to  the  cause  of  the  imbecility,  whether  it  had  its 
origin  before  birth,  or  whether  the  disease  of  the  brain  first 
appeared  in  childhood,  we  distinguish, 

(a)   A  congenital  and 

(6)   An  acquired  imbecility. 

Congenital  imbecility  shows  itself,  in  the  great  majority 
of  cases,  in  the  first  years  of  childhood.  The  children  are  strik- 
ingly unruly,  obstinate,  sometimes  violent  toward  their  relatives, 
and  there  is  a  tendency  very  early  to  injure  their  playmates, 
brothers,  or  sisters.  An  inclination  to  lying,  a  joy  in  tormenting 
animals,  an  unmotived  change  of  disposition  distinguish  them, 
even  before  the  school  age,  as  peculiar.  They  are  lazy,  inatten- 
tive, and  make  little  progress  in  school;  frequent  punishments 
pass  without  effect,  only  to  make  them  even  more  stubborn  and 
obstinate.  If  they  are  the  children  of  the  well-to-do,  private 
teachers  are  employed,  the  schools  are  changed,  they  are  sent 
to  boarding-schools,  without  effecting  any  essential  change  in 
their  condition.  After  the  end  of  the  school  year,  during  which 
he  attends  but  few  classes,  the  imbecile  is  dismissed  by  his 
first  master  on  account  of  his  incapability  and  improprieties; 
he  goes  to  the  second  and  third,  with  like  result. 

When  he  is  sent  away  by  these,  if  his  means  fail,  he  becomes 
a  beggar  and  a  vagabond. 

In  contrast  to  these  active  imbeciles,  the  anergic  or  apathetic 
imbeciles   show   an   entirely   different   type.     They   are   distin- 


'^  Hammaberg.  Translated  by  Walter  Bercrer.  Leipzig,  1895.  Ziehen. 
Die  Geisteskrankheiten  des  Kindesalters.    Berlin,  1902. 

11 


162  Special  Psychiatry. 


guished  by  a  certain  indifference  and  quietude,  they  do  not  un- 
derstand how  to  play  with  other  children,  stand  aloof,  and  are 
quite  often  described  as  good  and  obedient.  Their  defect  is 
first  clearly  shown  when  they  go  to  school.  Here  they  are  not 
capable  of  concentration  (aj^rosexia),  do  not,  therefore,  under- 
stand their  tasks.  They  remain  in  the  lowest  classes,  and,  when 
they  leave  school,  may  make  a  living  if  they  take  up  an  occuj)a- 
tion  which  does  not  demand  special  independent  mental  powers, 
they  marry  and  pass  through  life,  if  no  special  accident  happens, 
without  their  mental  inferiority  becoming  generally  kno-mi. 
But  with  such  imbeciles  it  is  well  if  no  stumbling-block  impedes 
their  way,  for,  if  so,  they  stumble  and  cannot  surmount  their 
difficulties,  but  fail  mentally  and  materially.  To  this  class  of 
placid  imbeciles,  who  perform  their  task  in  the  country  as  field 
laborers,  belong  also  those  soldiers  who  fail  very  often  after 
entering  military  service  and  then,  after  many  pimishments, 
perhaps,  are  first  recognized  as  mentally  diseased. 

Finally,  a  third  class  of  imbeciles  should  be  mentioned, 
who,  without  showing  striking  disturbances,  seem  to  be  wonders, 
when  they  first  go  to  school,  on  account  of  their  special  abilities. 
At  a  certain  age,  but  especially  about  the  time  of  puberty,  the 
mental  develoj^ment  ceases  without  any  new  injurious  factor 
having  appeared.  Sometimes  this  cessation  occurs  suddenly, 
and  their  knowledge  ceases  with  what  they  have  already  learned. 

In  many  cases  hebephrenic  phenomena  appear,  generally 
with  hypochondric  complaints,  and  the  rapid  development  of 
an  idiocy,  which  Morel  has  called  precocious  dementia,  follows. 

In  acquired  imbecility  the  intelligence  generally  suffers 
only;  those  disturbances  in  the  feelings  and  the  activity  of  the 
mind  which  have  been  described  above  are  either  entirely  want- 
ing or  are  only  slightly  developed. 

Special    Symptomatology. 

1.  The  Power  of  Reproduction — Memory. 

In  a  number  of  imbeciles  the  memory  is  good,  sometimes  so 
good  that  the  h^-permnesia  of  these  imbeciles  is  commented  on. 
In  many  cases,  on  the  basis  of  this  excellent  memon%  imbeciles 
manifest  an  unusual  but  restricted  talent,  but  which  has  essen- 


Idiotism.  163 

tially  a  mechanical  character.  Thus  imbeciles  may  become 
mathematicians,  pianists,  artists,  and  the  like,  and  may  pose 
by  their  knowledge  of  languages  (polyglots),  or  by  reproducing 
cjitire  paragraphs  of  legal  documents. 

In  acquired  imbecility,  what  was  learned  before  the  disease 
started  may  generally  be  reproduced,  while  the  memory  is  weak- 
ened for  what  follows,  and  is  little  capable  of  grasping  and 
retaining  any  thing  new. 

■  2.  Thought 

The  weak-minded  reproduces  what  he  has  heard  or  what 
he  has  learned,  but  he  does  not  produce  anything.  If  he  utters 
judgments,  they  appear,  when  examined  closely,  ready-made  as 
he  has  heard  them  from  others.  4-  true  understanding  of  them 
is  wanting,  as  well  as  the  possibility  of  telling  how  the  judgment 
has  arisen.  Hence  these  judgments,  when  they  are  imperfect 
or  incorrect,  are  difficult  to  undermine  or  controvert,  since  the 
ideas,  which  form  the  basis  of  the  judgment  and  which  should 
be  corrected,  are  wanting.  The  imbecile  repeats  the  Ten  Com- 
mandments, he  understands  the  command  which  he  has  dis- 
obeyed, but  is  incapable  of  seeing  the  reasons  which  have  led 
to  the  divine  commandment  or  to  the  provisions  of  the  criminal 
code  which  he  has  transgressed. 

The  associations  of  the  imbecile  are  pathologically  dis- 
turbed, first,  because  he  lacks  the  normal  powder,  and,  secondly, 
because  they  are  perfected  too  slowly. 

From  the  lack  of  power  proceeds  the  want  of  energy  for 
the  execution  of  what  the  patient  has  decided  to  do.  He  often 
takes  up  something  new  with  good  intentions,  but  lacks  the 
persistence  to  complete  the  work  which  he  has  begun.  Much  is 
undertaken,  but  nothing  completed. 

If  the  rapid  intergrasping  of  the  associations,  the  contem- 
poraneous appearance  of  the  associating  and  contrasting  ideas 
is  necessary  for  a  healthy  judgment,  then  the  judgments  of 
imbeciles  suffer  from  the  slowness  with  which  they  are  perfected. 
Hence  imbeciles  are  generally  credulous,  are  laughed  at,  they 
are  often  used  as  cat's-paws  and  afterwards  find  their  interests 
injured.  New  religious  and  political  sects,  mysticism,  spirit- 
ualism generally  find  an  especially  large  number  of  adherents 


164  Special  Psycliiairy. 


among  imbeciles,  on  account  of  their  lack  of  judgment  which 
proceeds  from  the  above-mentioned  causes.  The  unsteadiness 
of  the  attention,  that  is,  the  lack  of  concentration  on  a  deter- 
mined idea  or  a  given  series  of  ideas,  is  connected  with  the  slight 
power  of  the  ideas. 

The   attention  of   imbeciles,   if   it   exists,   is    intermittent. 

Psychometrical  examination  has  attempted  to  represent  by 
figures  the  diminution  of  the  power  and  rapidity  of  the  associa- 
tions. Ziehen  finds  the  average  time  of  association  in  imbecile 
children  for  adding  1  to  a  number  equal  to  '°Vioo  of  a  second, 
while  in  healthy  children  the  time  is  on  an  average  ^^*''/ioo- 

The  imbeciles  as  a  rule  show  a  high  degree  of  egotism. 
Even  at  home  they  are  placed  after  their  healthy  brothers  and 
sisters,  scolded  and  punished  at  school,  in  life  driven  here  and 
there,  and  are  not  in  a  condition  to  recognize  the  cause  for  their 
own  lack  of  worth;  they  behold  antagonists  everywhere,  and 
hence  believe  that  they  are  forced  to  place  their  own  interests 
foremost  in  their  strife  with  the  external  world.  Without  altru- 
istic feelings,  their  love  for  the  Ego  increases,  and  quite  often 
the  overstrained  care  for  their  own.  well-being  leads  to  hypochon- 
dric  anxiety.  On  the  other  hand,  egotism  often  calls  forth 
boastfulness,  and  the  impulse  for  the  satisfaction  of  egotistic 
objects  allows  immoral,  punishable  actions  to  take  place  from 
the  lack  or  slight  strength  of  contrasting  ideas.  So  far  as  con- 
cerns the  question  of  the  enjo}Tnent  or  the  defense  of  the  Ego, 
a  peculiar  cunning  is  often  developed. 

The  injuries  which  the  imbecile  receives  from  others  in- 
crease his  suspicion  of  his  environment  to  ideas  of  detraction 
or  prejudice,  even  to  delusions  of  persecution,  which  are  dis- 
ting-uished  from  those  of  paranoia  by  their  shallowness  and  by 
their  variability. 

3.  Anomalies  of  the  Feelings. 

(a)  The  sensual  feelings.  ]\Iany  imbeciles  show  a  path- 
ological heightening  of  the  sensual  feelings :  gluttony,  inclina- 
tion to  excesses  in  Baccho  and  in  venery;  others,  again,  show  a 
depression,  especially  in  the  province  of  sexualit}^,  or  perversi- 
ties; sometimes  abnormalities  in  this  direction  are  not  present. 
A  feeling  of  disease  exists  only  exceptionally  in  imbeciles. 


Idiotism.  165 

(b)  TliG  feelings  of  judgment.  Since  the  ideas  are  want- 
ii/g  in  strength,  and  hence  are  superficial,  in  the  same  manner 
the  feelings  of  judgment  are  subject  to  facile  changes.  The 
egotistic  feelings  remain  dominant,  the  altruistic  feelings  are 
weak  or  not  present.  Friendship  and  thankfulness  subsist  as 
long  as  they  harmonize  with  his  proper  interest,  and  are  quite 
often  expressed  in  the  most  fawning  manner.  Such  turn  around 
and  become  the  gravest  accusers,  if  self-interest  is  apparently 
endangered.  In  regard  to  the  religious  feelings,  the  imbecile  is 
often  distinguished  by  a  maudlin  sentimentality;  but  he  curses 
God  and  the  world  if  he  meets  with  a  mishap.  The  dispositions 
of  imbeciles  correspond  to  the  superficiality  of  their  ideas  and 
changing  feelings — now  depressed,  now  exalted,  now  scornful, 
now  excessively  devout. 

4.  Action. 

(a)  A  class  of  imbeciles  take  care  of  the  labor  assigned 
them  regularly  and  punctuall}^,  but,  as  said  above,  no  unexpected 
or  sudden  obstruction  should  be  placed  in  their  way. 

These  anergic  imbeciles  are  sometimes  less  distinguished 
by  the  abnormal  actions  which  they  perform  than  by  neglecting 
certain  things  which  a  normal  person  would  have  carried  out. 

(&)  Other  imbeciles  are  incited  to  activity  only  with  diffi- 
culty. They  will  begin  "to-morrow."  They  do  not  rise  early, 
stay  for  hours  in  one  place,  take  a  long  time  to  clothe  themselves, 
and  the  like. 

(c)  There  are  imbeciles  who  are  easily  excited  and  irri- 
tated; with  lack  of  judgment  they  run  after  all  sorts  of  fancies 
and  vagaries,  and  do  not  lead  a  regular  life  on  this  account. 

(d)  Another  class  of  imbeciles  are  distinguislied  from  3'outh 
by  an  inclination  to  immoral  actions.  They  have  been  described 
above  as  active  imbeciles.  By  far  the  greatest  number  of  those 
diseased  individuals  who  have  been  described  as  morally  insane 
belong  here. 

Sometimes  the  action  is  directed  preferably  to  carrying 
out  a  certain  kind  of  transgression,  and  people  then  speak  falsely 
of  a  monomania  (kleptomania,  and  similar  conditions),  while 
they  have  overlooked  the  other  pathological  phenomena. 

With  regard  to  the  mental  disease  of  the  transgressor  in 


166  Special  Psycliiatry. 


these  crimes  being  too  often  unrecognized,  and  the  motive  of 
the  punishable  action  being  falsely  judged,  the  following  should 
be  emphasized  concerning  those  immoral  and  criminal  actions : — 

1.  The  above-mentioned  pathological  egotism  incites  to 
gain  as  much  advantage  as  possible  for  the  person  himself. 

2.  Many  imbeciles  wish  to  obtain  satisfaction  for  the  in- 
juries which  they  believe  others  have  inflicted  ujDon  tliem  inten- 
tionally or  unintentionally,  or  to  revenge  themselves. 

3.  The  want  of  moral  feelings  opposes  no  restraint,  or  not 
strength  enough  to  the  carrying  out  of  the  actions  in  1  and  2. 

4.  The  want  of  judgment  does  not  allow  the  imbecile  to 
recognize  the  consequences  of  the  contemplated  or  completed 
action. 

5.  The  imbecile  is  often  led  into  misfortune  by  being  easily 
persuaded  by  others.  Quite  often  he  is  the  instrument  of  other 
normal  criminals.  Here,  also,  belongs  the  phenomenon  of  the 
imbeciles  Avho  have  a  great  inclination  to  imitation. 

6.  The  imbecile  often  acts  impulsively,  yielding  to  the 
momentary  impulse;  the  strength  of  the  impulse  hinders  the 
consideration  which  should  precede  the  action. 

7.  In  weighing  man}^  of  the  acts  already  mentioned,  the 
intolerance  of  many  imbeciles  to  alcohol  should  be  considered. 

These  active  imbeciles  are  to  be  designated  as  anti-social. 

The  physical  changes  which  accompany  imbecility,  its  eti- 
ology, and  diagnosis  will  be  considered  in  connection  with  the 
discussion  on  idiocy. 

The  course  of  imbecility  shows,  in  a  series  of  cases  under 
favorable  circumstances,  a  uniform  pathological  type,  reaching 
into  an  advanced  age.  Sometimes  intercurrent  hallucinations 
appear  which  may  bring  on  delusions.  The  halhicinations  like 
the  delusions  are  not  very  complicated,  corresponding  to  the 
limited  intellectual  acquirements.  On  the  basis  of  imbecility 
arise  sometimes  transitory  periodical  states  of  depression  and 
exaltation,  which  generally  leave  behind  a  further  injury  to  the 
mental  power.  Sometimes  paranoia  develops  on  the  basis  of 
imbecility.     Paresis  appears  only  very  exceptionally  in  imbeciles. 

The  complication,  often  observed,  of  imbecility  with  alco- 
holism entails  the  most  serious  injuries  to  the  remaining  mental 
powers. 


Idiutism.  167 

2.  Idiocy.^ 

We  distinguish  here,  as  in  iiiibecility : — 

(a)   The   Congenital    Form. 

The  children  are  recognized  as  abnormal  even  in  the  first 
months  of  life.  They  show  great  helplessness  in  feeding  at  the 
breast  or  from  a  bottle,  and  seize  the  nipple  with  great  difficulty. 
]\Iany  sleep  constantly  and  can  hardly  be  awakened,  others  cry 
obstinately  day  and  night.  The  smile  of  the  developing  child 
is  wanting,  as  well  as  the  Joyful  kicking  when  the  hampering 
swaddling  clothes  are  removed.  Sometimes  johysical  signs  of 
paralj^sis,  spasms,  marks  of  degeneration  confirm  the  diagnosis 
of  idiocy  in  the  first  months  of  life. 

In  its  further  course  defective,  or  want  of  development  'of 
the  mental  activity  appears  in  a  more  or  less  striking  manner 
and  in  very  different  degrees. 

As  a  rule,  the  highest  degree  of  idiocy  does  not  even  reach 
a  stage  of  mental  activity;  the  face  remains  expressionless,  is 
not  moved  by  laughter  or  tears;  there  is  no  development  of 
speech,  at  the  most  only  inarticulate  sounds  are  uttered;  the 
child  does  not  recognize  those  nearest  to  him;  it  must  be  fed, 
or  else  greedily  devours  its  food;  it  soils  itself  continually,  and 
in  many  cases  does  not  have  the  capability  of  moving  about. 

Between  this  highest  degree  of  idiocy  in  which  an  intel- 
lectual life  is  totally  wanting  and  the  imbecility  just  described, 
there  is  a  long  series  of  transitions,  whose  essential  symptoms 
will  be  shown  in  the  special  symptomatology. 

(b)  The  Acquired  Form. 

The  child  does  not  show  any  abnormalities  before  it  is  at- 
tacked by  the  disease  which  stops  the  further  development  of  the 
brain.  Here  the  signs  of  degeneration  generally  are  absent. 
According  to  the  age  in  which  the  disease  attacks  the  child,  and 
according  to  the  intensity  with  which  it  destroys  what  has 
been  acquired,  the  idiot  will  present  a  very  different  type  in  his 
later  life. 


'  Idiot  is  derived  from  i5tos,   isolated,  because  he  is  not  in  a  state 
to  associate  with  others. 


168  Special  Psychiatry. 


Special   Symptomatology   of   Idiocy. 

1.  The  Sense  Perceptions. 

In  the  severest  forms  of  idiocy  there  are  generally  no  sense 
perceptions.  The  light  is  felt,  but  its  significance  is  not  recog- 
nized. Such  children  hear,  but  they  do  not  learn  to  understand 
the  meaning  of  the  words.  Identification  also  fails;  the  child 
knows  its  mother,  but  does  not  know  its  bed. 

A  condition  is  present  in  which  a  sense  perception  has  never 
taken  place,  hence  hallucinations  cannot  appear  later.  Like- 
wise, intercurrent  hallucinations  appear  in  idiots,  even  if  they 
do  not  have  the  intensity  and  significance  of  the  hallucinations 
of  other  mental  diseases.  Infectious  diseases  of  children,  which 
frecjuently  condition  hallucinations  and  deliria,  are  wont  to  call 
them  forth  in  idiotic  children  onl}'  exceptionally  and  to  a  limited 
degree. 

2.  The  Power  of  Reproduction — Memory. 

In  pronounced  cases  memory  does  not  generall}^  exist.  It  is 
present  in  those  of  less  degree,  and  on  its  development  depend 
special  capabilities  which  are  sometimes  found  in  congenital 
idiots. 

3.  Thought. 

The  capability  of  forming  judgments,  drawing  conclusions, 
is  wanting  in  idiots.  Although  it  may  apparently  be  present, 
it  is  onl}^  the  reproduction,  through  memory,  of  the  judgments 
of  others.  While  many  idiots  can  add  and  subtract,  they  are 
capable  of  multiplying  and  dividing  only  exceptionally.  Idiots 
do  not  acquire  the  conception  of  time  and  space  -except  defect- 
ively. The  average  degree  of  normal  intelligence  corresponding 
to  their  age  is  often  used  as  a  means  of  comparison ;  we  say,  e.g., 
a  twelve  years'  idiot  has  the  same  intelligence  as  a  child  of  three. 

4.  Tlie  Feelings. 

The  sensory  feelings,  the  feelings  of  hunger  and  thirst  are 
diminished  in  many  idiots ;  on  this  also  rests  the  lack  of  feeling 
of  satiety.  In  spite  of  masturbation,  which  is  found  in  many 
idiots,  it  must  not  be  assumed  that  thev  have  the  sexual  feelings 


Idiot  ism.  169 

heightened.  The  sexual  impulse  often  expresses  itself  towards 
others  in  a  shameless  and  reckless  way.  Idiots  have  only  excep- 
tionally the  feeling  of  disease,  and  in  the  feelings  of  judgment 
only  the  egotistic  feeling  is,  as  a  rule,  well  developed. 

According  to  their  external  behavior,  we  distingiiisli  apa- 
thetic and  anergic  idiots  from  eretkic  and  versatile^  wliich  latter 
are  now  serene,  caressing  and  kissing  continually,  now  again 
weeping,  striking,  and  screaming. 

The  malignant  or  vicious  idiots  are  mostly  the  product  of 
rough  treatment,  repeated  punishments,  and  constant  abuse. 

Finally,  there  are  idiots  of  constant  good-humor,  who  are 
designated  as  companionable  idiots. 

5.  Speech. 

Some  idiots  are  mute,  either  because  they  have  not  acquired 
word  images  (deaf-mute  idiots),  or  because  they  lack  ideas 
which  they  can  express  {alogia,  alogic  idiots,  idiotic  mutism), 
or  because  they  have  no  need  to  express  by  speech  the  ideas 
which  the}^  possess,  or  because  a  motor  speech  center  has  not 
developed  or  has  been  destroyed  by  disease  {motor-a phasic 
idiots),  or,  finally,  because  the  motor-conducting  apparatus,  for 
ideas  of  speech  has  not  been  developed  or  has  been  destroyed 
{anarthric  idiots) . 

Those  idiots  who  do  talk,  generally  begin  after  the  fourth 
year  or  later.  Many  acquire  only  single  words,  others  do  not 
reach  the  normal  formation  of  sentences  (akataphasia,  infinitive 
speech),  others  stammer  (dysarthria  literalis).  Stuttering  is 
rare  in  idiots,  while  it  is  frequent  with  imbeciles.  Many  idiots 
lisp,  others  speak  with  a  peculiar  accent,  and,  finally,  there  are 
so-called  "eternal  babblers"  among  patients  with  acquired  idiocy, 
who  talk  unceasingly  without  understanding  what  is  said.  In 
spite  of  the  defect  of  speech,  many  idiots  learn  to  sing  very  well. 

The  disturbance  in  speech  corresponds  to  those  in  reading 
and  writing.  A  great  number  of  idiots  generally  do  not  learn 
to  read,  and  by  far  the  greater  number  do  not  learn  to  write. 

6.  The  Physical  Condition: 

Ehachitis  and  scrofula  are  very  frequent  in  idiots.  Con- 
nected with   the  last   is   the   frequent   appearance   of   adenoid 


170  Special  Psychiatry. 


growths  in  the  naso-pharyngeal  vault,  upon  which  some  have 
tried  to  lay  the  impossibility  of  concentrating  the  attention  on 
a  determined  object  (aprosexia,  Guye).  In  the  great  majority 
of  the  cases,  so-called  signs  of  degeneracy  are  found  in  idiot>, 
long  arms,  short  legs,  abnormal  formation  of  the  cranium,  dis- 
turbances in  the  formation  of  the  teeth,  and  other  stigmata  of 
the  various  organs. 

Strikinglj'  frequent  are  ambidextrous  idiots,  while  right- 
and  left-handedness  are  met  as  frequently  as  in  normal  indi- 
viduals. While  some  idiots  are  heav}"  and  clumsy  in  their 
motions,  others  show  a  monkey-like  activity.  Automatic  move- 
ments, nodding,  shaking  the  head,  swinging  the  body  to  and 
fro  are  often  observed. 

"We  distinguish  as  a  j)eculiar  subclass  of  idiotism  paralytic 
imbecility  or  idioc}',  states  of  bodily  paralysis  and  contractures 
which  have  generally  proceeded  from  those  diseased  states  of 
the  brain  and  its  membranes  which  are  designated  as  spastic  cere- 
hral  palsies  of  children.^  The  paralyses  are  either  hemiplegic, 
diplegic,  or  paraplegic,  quite  often  coimected  with  athetosis. 
Abortive  forms  appear  frequently,  which  can  be  distinguished 
by  the  exaggerated  tendon  reflexes,  in  spasms*  of  the  lower  ex- 
tremities {paraspasmus  cerehralis) ,  or  of  the  upper  extremities 
without  paralyses  {dispasmus  cerehralis),  in  other  cases  only  by 
sporadic  muscular  paralyses  (Konig). 

A  further  subclass  of  idiotism  is  constituted  by  that  form 
which  is  connected  with  epilepsy  (epileptic  imbecility  or  epi- 
leptic idiocy).  The  epileptic  seizures  in  the  congenital  form 
often  appear  in  the  first  months  after  birth,  may  vanish  later 
or  be  replaced  by  epileptic  equivalents.  In  later  life  (about  the 
fortieth  year)  epileptic  seizures,  which  have  previously  been  pres- 
ent with  idiots,  generally  disappear. 

Almost  a  third  of  all  cases  of  idiocy  are  transitorily  or 
permanently  accompanied  by  ej^ileptic  seizures. 

7.  Sensory  Organs  and  Cutaneous  Sensations. 

Five  per  cent,  of  all  idiots  have  congenital  or  acquired 
blindness.     A  peculiar  form  which  has  been   described  under 


"•  Wachsmutli.     Cerebrale  Kinderlalimuug  luid  Idiotie.     Arehiv  fiir 
Psychiatrie,  1901,  xxxiv,  3. 


Idioiism.  1/1 

the  name  of  Sack's  amaurotic  family  idiocy  (Warren  Tay, 
1881^)  shows,  besides  the  atrophy  of  the  optic  nerves  (in  the 
region  of  the  macula  lutea  a  red  spot  surrounded  by  a  white 
halo;  according  to  the  observations  so  far  made,  not  congenital, 
but  arising  in  the  first  years  of  life),  weakness  or  even  paralysis 
of  the  entire  musculature  of  the  body. 

Congenital  or  accpiired  deafness  in  idiots  is  rarer  than 
blindness. 

The  sense  of  touch  and  muscle  sense  are  generally  dimin- 
ished. 

The  reflexes  show  abnormalities  only  in  the  paralytic  form 
of  idiotism. 

Etiology. — The  ratio  of  the  frequency  of  idiotism  in  boys 
and  girls  is  as  two  to  one.  The  percentage  of  the  first-born  is 
strikingly  large  (Langdowne,  24  per  cent.). 

The  ratio  of  congenital  to  acquired  idiotism  is  as  three  to 
one. 

Idiotism  may  arise  from  the  following  causes : — 

1.  In  the  germ:  Marriage  among  blood  relatives  (consan- 
guinity), begetting  in  drunkenness,  a  wide  disparity  in  the 
ages  of  the  parents,  mental  disease  or  severe  neuroses  of  the 
parents,  alcoholism  (in  10  to  20  per  cent,  of  all  the  cases  of 
idiocy),  morphinism  of  the  parents. 

2.  In  injuries  which  affect  the  fetus :  Traumata  of  the 
uterus,  psychic  shocks  to  the  mother,  diseases  of  the  mother 
during  pregnancy,  hereditary  syphilis;  seldom  hereditary  tuber- 
culosis. 

3.  In  injuries  at  birth :  Delayed  parturition  with  con- 
tracted pelvis,  use  of  forceps  with  impressions  on  and  fractures 
of  the  cranial  bones.  These  cases  are  generally  connected  with 
Little's  disease. 

4.  In  the  injuries  received  after  birth,  in  which  the  hered- 
itary basis  may  also  cooperate  as  a  coefficient;  injury  to  the 
head,  binding  the  head  of  the  child,  remedies  used  to  keep  the 
child  quiet  (alcohol,  opium  compounds),  which  the  nurses  or 
attendants  administer,  diseases  of  infancy,  especially  cholera 
infantum  in  the  first  years  of  life,  scarlatina,  also  syphilis,  and 
the  like. 


^Frey.     Neurologisclies  Centralblatt,  1901,  836. 


172  Special  Psychiatry. 


Pathological  Anatomy.^ 

The  cranium  very  often  shows  the  following  defects : — 

Microcephalus,  hydrocephalus,  skaphocephalus,  the  Mongol 
type,  plagiocephalus ;  narmocephalus  and  progenic  cranium  are 
also  observed. 

Broca  designates  as  microcephalic  all  brains  of  1019  grams 
or  less  in  men,  or  of  907  grams  or  less  in  women.  See  chapter 
on  Degeneration. 

He  divides  microcephalus  into  (1)  true  (absolute  arrest  of 
development),  (2)  pseudomicrocephalus,  where  pathological  pro- 
cesses may  be  shown,  and  (3)  the  combined,  the  combination  of 
the  two  preceding. 

Microcephalic  idiots  are  alwa3's  excited,  irritable,  with  a 
lively  expression  of  the  countenance,  often  loquacious;  the  hy- 
drocephalic idiots,  on  the  contrary,  are  generally  apathetic,  with 
expressionless  face,  rarely  excited,  and  move  about  very  little. 

Pachymeningitis,  meningitis,  adhesions  of  the  membranes 
to  each  other,  to  the  inner  vault  of  the  cranium,  or  to  the  surface 
of  the  brain,  are  often  found  in  idiots. 

The  weight  of  the  brain  is  very  much  diminished,  especially 
so  in  microceiDhalics.  Yet  there  are  occasional  strikingly  heavy 
brains,  especially  in  tuberous  hypertrophy  of  the  brain. 

Porous-like  defects  in  the  lobes  of  the  cerebrum  (poren- 
cephalus,  Heschel,  1859),  microgyria,  suiaerficial  folds  and  fis- 
sures of  the  cortex  with  very  small  convolutions,  very  serpentine, 
sometimes  with  great  development  of  the  gray  and  less  of  the 
white  substance,  absence  of  the  corpus  callosum,  defective  devel- 
opment of  the  operculum,  of  the  cerebellum,  and  heterotopia  of 
the  gray  substance  are  occasionally  found.  Sometimes  islets 
of  sclerosis  distributed  throughout  the  brain  are  present.  With 
these  are  often  found  pathological  changes  in  the  spinal  cord, 
as  hydromyelia,  syringomyelia. 

The  microscopic  examination  often  shows  the  ganglion  cells 
of  normal  frequency  and  consistency.  The  abnormal  condition 
is  then  to  be  sought  preferably  in  the  pathological  change  of  the 
association  fiber  svstems. 


''■  Schiitte.      Zusammeiifasseiides     Referat.      Centralblatt     fiir     all- 
gemeine  Pathologie  u.  Pathologische  Anatomic,  1900. 


Idiotism.  173 

The  course  in  acquired  idiocy,  especially  where  epileptic 
seizures  are  frequent,  is  progressive,  while  the  mental  weakness 
increases  more  and  more.  States  of  excitation  and  depression 
appear  intercurrently  both  in  imbecility  and  idiocy.  Severe 
cases  of  idiocy  seldom  reach  an  age  of  over  thirty  years. 

Diagnosis. — For  the  proof  that  imbecility  or  idiocy  exists, 
it  must  be  shown  in  the  first  place  that  there  is  a  chronic  condi- 
tion of  mental  weakness.  All  possible  forms  of  mental  disease 
may  appear  in  childhood,  which  must,  however,  not  be  reckoned 
Avith  idiotism.  But  if  a  chronic  condition  of  mental  weakness 
is  shown  in  adults,  the  next  question  will  be  whether  it  was 
congenital,  or  arose  in  early  youth,  or  whether  it  first  appeared 
after  the  brain  had  attained  its  full  normal  development.  Eight 
here  the  anamnesia  must  be  the  decisive  factor  and  supply  the 
information  concerning  what  the  patient  has  already  experi- 
enced in  the  course  of  his  life.  If  idiotism  is  p'roved,  it  will  be 
necessary  to  ascertain  further  whether  it  is  congenital  or  ac- 
quired, whether  it  is  complicated  with  epilepsy  or  paralysis. 

Differentio-diagnostically  in  imbecility,  it  is  of  the  utmost 
importance  to  determine  whether  it  concerns  a  person  but  little 
developed  mentally  or  one  mentally  diseased.  The  degree  of 
mental  development  which  a  man  may  attain  is  dependent  not 
only  upon  the  normal  or  pathological  conditions  of  the  brain, 
but  also  upon  the  precept,  the  training,  the  education ;  in  short, 
his  environment. 

Hence,  in  framing  the  clinical  picture  of  an  imbecile  we 
miist  make  a  complete  history  of  his  whole  mental  development. 
What  may  seem  to  be  weak-mindedness  in  a  professional  man, 
may  appear  normal  in  a  shepherd. 

If  there  are  physical  signs  of  brain  disease,  like  paralytic 
states,  epilepsy,  very  extended  and  considerable  stigmata  of 
degeneration,  then  the  retardation  of  the  mental  development 
may  be  all  the  more  easily  diagnosed  as  pathological. 

The  boundary  betAveen  idiocy  and  imbecility  is  evanescent. 
We  designate  as  imbecility  that  grade  of  idiotism  in  which  the 
patient  is  able  to  follow  a  calling,  when  he  is  a  part  of  life,  while 
the  idiot  simply  occupies  space  and  performs  no  function  in  the 
body  politic. 

Finally;  it  is  to  be  mentioned  that  paresis  in  children  may 


174  Special  Psychiatry. 


make  the  impression  of  an  idiotism.  Here  the  proof  of  hered- 
itar}'  syphilis  or  that  acquired  in  childhood,  together  ^vith  the 
absence  of  the  pupillary  reflex,  abnormalities  in  the  tendon 
reflexes,  especially  paralytic,  disturbances  of  the  speech  and  the 
progressive  course,  are  of  differential  significance  in  reaching  a 
diagnosis.    ' 

Prognosis. — Idiotism  is  an  incurable  disease.  Improve- 
ment in  the  mental  condition  of  epileptic  idiots  after  suitable 
treatment  for  epilepsy  is  often  observed.  The  acquired  form  of 
idiocy  is  most  unfavorable  prognostically  in  reference  to  reach- 
ing a  certain  degree  of  mental  development. 

Treatment. — Prophylaxis  must  regard  all  those  injuries  in 
the  ascendant  which  have  been  previously  mentioned:  Dissuade 
marriage  among  blood  relations,  marrying  mentally  diseased  or 
very  nervous  persons,  limitation  of  the  use  of  alcohol,  and  re- 
striction in  the  spread  of  syphilis. 

In  imbeciles  much  may  l^e  accomplished  by  employing  them 
in  occupations  suitable  to  their  capacities.  The  help  classes  and 
help  schools  vhich  are  at  present  becoming  more  numerous  are 
a  very  suitable  aid  to  the  individual  imbecile. 

In  the  treatment  of  idiocy  the  first  question  is  whether  the 
child  should  be  taken  to  an  institution  or  be  treated  at  home. 
After  the  first  six  ^-ears  of  life  it  is  but  seldom  that  an  idiot  can 
be  taken  care  of  properly  in  a  family.  The  interests  of  the  sick 
child  and  of  his  healthy  brothers  and  sisters,  finally  the  condi- 
tion of  the  nervous  parents,  demand  that  he  should  be  taken  to 
an  institution.  If  there  are  epileptic  seizures,  bromide  should  l^e 
given  with  or  without  belladonna,  in  doses  once  a  day  of  from 
two  to  three  or  four  grams,  according  to  the  age.  In  hydro- 
cephalus one  should  try  lumbar  puncture  or  even  cranial  punc- 
ture. Craniectomy  should  be  practiced  in  idiotism  only  when 
there  are  indications  which  would  justify  trephining  in  non- 
idiotic  states,  as  depressions  of  the  cranium  or  fractures  of  the 
cranium.    Microcephalus  of  itself  offers  no  indication. 

Thyroid  treatment  is  of  value  only  in  cretinic  idiotism 
(which  see).  The  diet  in  idiotism  should  be  nourishing  and 
non-irritating.  Alcoholic  drinks  should  be  forbidden,  all  the 
more  since  imbeciles  are  very  often  susceptible. 


The  Functional  Psychoses:  Delirium  Hallucinatorium.  175 

II.  THE  FUNCTIONAL  PSYCHOSES. 

1.  Delirium  Hallucinatorium.^ 

Delirium  hallucinatorium  is  a  functional  psychosis  ivhose 
beginning  and  course  are  characterized  by  sense  deceptions  and 
a  considerable  limitation  of  the  self -consciousness.^ 

After  a  short  preliminary  stage  (a  few  days,  up  to  a  week), 
in  Avliich  headaches,  feelings  of  anxiety  generally,  also  sporadic 
hallucinations  and  especially  insomnia  exist,  the  disease  mani- 
fests itself  plainly  and  may  run  its  course  in  three  different 
ways. 

(a)  Active    Delirium    Hallucinatorium. 

The  patient  talks  confusedly,  is  incoherent,  and  is  deter- 
mined in  his  actions  through  vivid  and  rapidly  changing  hallu- 
cinations, sometimes  in  several  senses,  often  in  all  the  senses. 
ISTow  he  seems  excessively  serene  and  fortunate,  kisses  and  em- 
braces those  around  him,  claps  his  hands  for  joy;  then  he  seems 
very  unhappy,  curses  and  strikes  whomever  and  whatever  he  can 
reach.  Meanwhile  there  are  single  exclamations  which  show  a 
return  to  consciousness  for  a  short  time,  as  "My  head  is  very 
much  confused."  The  delusions  which  are  produced  are  unsys- 
tematized; self -accusations  and  expansive  ideas,  narratives  of 
fantastic  stories  of  his  own  life  or  of  those  of  another  whom  he 
connects  with  himself,  are  wildly  intermingled. 

The  patient  does  not  know  where  he  is,  and  knows  just  as 
little  about  the  time ;  he  fails  to  recognize  his  surroundings  or 
the  persons  and  things  around  him.  Sometimes  his  excitement 
rises  to  raving. 

The  sense  deceptions  gradually  abate,  the  patient  becomes 
calmer,  and  as  a  rule  recovers  in  the  course  of  a  few  months. 

(b)  Passive   Delirium  Hallucinatorium. 

The  patient  lies  quietly  in  bed,  or,  while  fully  or  partially 
clad,  moves  around  the  room.     He  speaks  little  or  not  at  all, 


^  Halliicinatorisches  Irresein  (Fiierstner).     Amentia  (Meynert). 
-  Wille.   Archiv  fiir  Psychiatrie,  1888,  xix.    Ses;las.    Presse  medicale, 
1897,  22.    Meyer.    Arcliiv  fiir  Psycliiatrie,  1899,  xxxii,  780. 


176  Special  Psychiatry. 


3et  his  countenance  shows  his  intentions  as  they  mature;  now 
he  smiles,  again  he  seems  anxious  and  frightened,  closes  his  eyes 
fast,  or  stares  straight  ahead.  As  in  the  first  form,  there  is  an 
absence  of  orientation. 

From  this  tranquil  form  an  anxious  stupor  is  sometimes 
developed.  The  strained  and  anxious  expression  of  the  coun- 
tenance shows  that  depressive  ideas  force  the  patient  to  the 
unnatural  demeanor,  and  the  convalescent  relates  the  horrible 
situations  through  which  he  has  passed  at  the  time  of  his  seem- 
ingly ph3-sical  and  mental  rigidity.  More  rarely  a  stupor  ap- 
pears with  katatonic  symptoms. 

(c)  In  some  cases  there  is  an  interchange  of  the  symptoms 
of  the  active  and  passive  form. 

Special  Symptomatology. 

1.  lUiisions  and  hallucinations.  Visual  illusions  play  a 
great  role  in  delirium  hallucinatorium  and  appear  to  be  the 
chief  cause  of  the  defective  orientation.  Besides  these  and  the 
auditory  hallucinations  of  the  most  diverse  forms,  the  kinesthetic 
hallucinations  are  to  be  emphasized.  The  patients  are  dis- 
quieted by  a  rolling  of  their  bodies  or  by  a  change  of  position, 
as  if,  e.g.,  they  were  at  sea;  they  feel  themselves  lifted  up  and 
lowered  in  bed,  and  they  think  that  they  are  raised  to  heaven 
or  sunk  into  the  earth,  the  delusions  shaping  themselves  upon 
the  happening  which  caused  the  deception. 

The  tendency  of  the  hallucinations  to  change  distinguishes 
the  active  form,  while  their  stability  accompanies  the  passive. 

2.  Delusions.  As  already  mentioned,  depressive  and  ma- 
niacal ideas  interchange  incoherently  in  rapid  succession.  Xow 
the  patient  is  God  the  Father,  noAv  the  devil  incarnate.  At  one 
time  he  sees  everything  in  heavenly  light,  at  another  he  believes 
that  everything  will  l)e  destroyed  by  fire. 

It  should  be  emphasized  as  of  considerable  diagnostic  im- 
portance that  no  system  exists  in  reference  to  the  connection 
of  the  delusions  with  one  another. 

3.  The  frame  of  the  mind  corresponds  with  the  contents 
of  the  delusions. 

4.  There  is  generally  a  certain  degree  of  amnesia  covering 


The  Fundional  I'si/clioscs:  Dellnum  IlaUucinaioriiiiu.  177 

the  period  of  the  disease.     Only  the  chief  events  are,  as  a  rnlo, 
remembered. 

Sometimes  a  retrograde  amnesia  appears  and  a  certain 
period  of  time,  antedating  the  onset  of  the  disease,  disappears 
from  memor3\ 

5.  The  self-consciousness  is  very  much  clouded,  and  in  the 
liighest  grade  of  the  disease  it  is  entirely  extinguished.  The 
hallucinations  call  forth  by  their  massiveness  and  their  ever- 
chtinging  images  a  confusion  which  belongs  to  the  characteristic 
symptoms  of  delirium  hallucinatorium.  In  the  meantime  there 
are  often  sudden,  but  not  enduring,  lucid  intervals,  or  clearing 
up  of  the  self-consciousness :  "Where  am  I  ?"  "I  have  certainly 
been  demented,"  and  the  like. 

6.  The  speech  sometimes  shows  changes  which  are  ex- 
pressed in  verbigeration,  in  lingual  delirium,  often  in  the  for- 
mation of  strange  words  (paraphrasia  vesana) . 

7.  As  for  the  physical  symptoms,  sleep  is  generally  dis- 
turl^ed,  the  repugnance  to  the  taking  of  nourishment  may  reach 
to  sitophobia.  With  this  the  pulse  and  temperature  show  noth- 
ing abnormal.  A  rise  in  the  temperature  of  the  body  awakens 
a  suspicion  of  physical  complications.  The  tendon  reflexes  are 
apt  to  be  somewhat  increased,  symptoms  of  an  organic  disease 
of  the  central  nervous  system  are  wanting. 

Etiology. — A  large  majority  of  the  patients  suffering  from 
delirium  hallucinatorium  are  never  brought  to  the  knowledge 
of  the  psychiatrist,  and  the  disease  runs  its  course  in  the  homes 
of  the  patients,  in  the  surgical,  internal,  or  gynecological  clinics. 
Men  are  more  frequently  attacked  than  women.  The  disease 
appears  especially  in  the  third  and  fourth  decennia  of  life. 
Hereditary  basis  may  be  considered  a  predisposing  factor,  as  in 
most  psychoses. 

Among  the  direct  causes,  infectious  diseases  and  the  puer- 
perium  (two-thirds  of  all  cases  of  the  so-called  puerperal 
psychoses  follow  in  the  type  of  delirium  hallucinatorium)  play 
the  greatest  part;  furthermore,  operations,  especially  abdominal 
operations,  lithotomy,  and  the  like,  then  traumata  which  are 
connected  with  psychic  shock  (railway-brain). 

The  outhreak  is  generally  subacute;  the  course  has  been  de- 

12 


178  Special  Psychiatry. 


scribed  above.  There  are  rare  forms  in  which  delirium  hallu- 
cinatorium  appears  periodically. 

The  duration  of  the  disease  varies  between  fourteen  days 
and  six  months,  but  it  may  last  over  a  year  and  still  be  cured. 

The  results  are : — 

1.  Recovery.  Delirium  hallucinatorium  is  by  far  the  most 
favorable  form  prognostically  of  all  the  functional  psychoses. 
The  percentage  of  recoveries  amounts  to  about  80  per  cent.;  if 
the  institutions  show  one  much  smaller  (45  per  cent.),  it  is  be- 
cause the  cases  running  rapid  and  favoralile  courses  do  not,  as  a 
rule,  enter  an  institution,  but  recover  at  home  or  in  the  general 
hospitals. 

2.  Clironic  mental  disease  under  the  t}-pe  of  terminal  de- 
mentia, sometimes  with  concentration  of  the  hallucinations  and 
delusions  into  a  system,  passing  into  a  paranoia  hallucinatoria 
chronica. 

3.  Death,  which  is  brought  on  by  those  causes  which  have 
called  forth  the  psychosis  (operation,  trauma,  puerperal  and  in- 
fectious diseases),  or  by  injuries  which  the  patient  has  inflicted 
upon  himself  in  the  stage  of  raving  or  has  suffered  from  others, 
or,  finally,  by  general  exhaustion. 

Diagnosis. — To  the  diagnosis  of  delirium  hallucinatorium 
belong : — 

1.  The  jDroof  of  a  greater  or  less  degree  of  the  clouding  of 
the  self-consciousness. 

2.  The  proof  of  hallucinations  which  have  introduced  and 
dominate  the  clinical  type. 

3.  The  lack  of  the  symptoms  of  an  organic  disease. 
The  differential  diagnosis  must  regard : — 

1.  The  delirium  of  fever.  Here  the  thermometer  and  the 
anamnesia  are  the  deciding  factors. 

2.  Intoxication  and  abstinence  deliria.  Here  the  anam- 
nesia  and  the  presence  of  the  characteristic  s^'mptoms  of  the 
corresponding  toxins  may  confirm  the  diagnosis. 

3.  Since  the  symptoms  of  delirium  hallucinatorium  may 
also  appear  interciirrently  with  melancholia,  with  paranoia,  in 
connection  with  hysteric  and  epileptic  seizures,  the  independence 
of  the  clinical  type  must  be  confirmed  if  one  would  designate  it 
as  delirium  hallucinatorium. 


The  Functional  Psychoses:  Delirium  Ilallucinatorium.  179 

4.  The  active  i'onn  of  delirium  liaiiucinatoriuiu  is  distiu- 
guislied  i'roiii  mania  by  tlie  inassiveness  of  the  hallucinations 
which  is  foreign  to  the  latter,  and  by  the  interchange  of  ma- 
niacal and  depressive  moods.  Further,  it  does  not  have  the 
ilight  of  ideas  and  the  mental  deviation  which  are  peculiar  to 
mania. 

5.  In  the  same  way,  the  passive  form  of  melancholia  may 
be  distinguished  from  the  passive  form  of  delirium  hallucina- 
torium  by  the  ever-changing  of  the  phenomena  in  the  latter  and 
the  slighter  clouding  of  the  self -consciousness  in  the  former. 

6.  The  delusions  in  paranoia  are  systematized,  but  all  sys- 
tem fails  in  delirium  hallucinatorium. 

7.  Externally,  the  immobility  in  acute  dementia  may  com- 
pare with  that  which  one  finds  in  the  passive  form  of  delirium 
hallucinatorium.  Yet  the  expression  of  the  countenance  and 
the  negativism,  which  latter  is  often  present  in  delirium  hallu- 
cinatorium, are  contrary  to  the  behavior  of  the  acutely  demented, 
in  whom  the  expression  of  the  face  is  completely  void,  and 
whose  behavior  to  the  external  world  shows  absolute  indiffer- 
ence. 

8.  From  the  delirium  of  collapse  (H.  Weber),  the  active 
form  of  delirium  hallucinatorium  is  distinguished  only  by  the 
peracute  beginning  of  the  former  and  its  rapid  course,  which 
often  leads  to  death.  The  clinical  pictures  are  the  same  in 
their  essential  features. 

So-called  acute  delirium  begins  with  fever,  while  delirium 
hallucinatorium  shows  a  rise  in  temperature  only  when  com- 
plications appear. 

Treatment. — In  the  majority  of  cases,  especially  in  the 
active  form,  it  is  advisable  to  transfer  the  patient  to  an  institu- 
tion. On  account  of  the  sudden  changing  of  the  symptoms,  care 
in  a  private  dwelling  is  not  expedient.  In  the  passive  form,  also, 
care  at  home  will  be  very  difficult  on  account  of  a  possible  sito- 
jihobia. 

If  the  patient  is  secure  in  an  institution  from  injuries  to  his 
own  person  through  the  hands  of  others  or  himself,  one  should 
the  rather  abstain  from  over-medication,  since  experience 
teaches  that  this  disease  generally  terminates  in  recovery  with- 
out medicines.     Rest  in  bed    and   non-irritating   food   are   de- 


180  Special  Psychiatry. 


inanded  above  all  else,  while  lukewarm  packs  or  i^rolonged  baths 
are  advisable. 

Continued  insomnia  is  combatted  by  one  or  two  glasses  of 
beer  or  a  glass  of  heavy  Avine.  Hypnotics  are  often  of  little 
value  in  ordinary  doses,  but  rather  excite  the  patient;  sleep 
and  rest  may  be  produced  transitorily  by  using  duboisin  in 
doses  of  one-half  to  one  milligram.  If  there  is  obstinate  sitopho- 
bia,  one  should  use  the  esophageal  sound  and  nourishing  clysters. 
Where  weakness  of  the  pulse  and  superficial  respiration  con- 
tinue in  the  stuporous  form,  camphor  injections  are  recom- 
mended, and  saline  infusion  may  be  used  in  conditions  of 
collapse. 

2.  Mania.i 

Mania  is  a  functional  psychosis  which  is  characterized 

1.  By  a  patliolcrgical  acceleration  of  the  efflux  of  ideas. 

2.  By  a  heightened  excitahiUty  of  the  motor  centers  of  the 
hrain. 

We  distinguish  four  stages  in  the  course  of  typical  mania : 

1.  The  initial  stage,  which  is  distinguished  by  depression, 
heaviness  in  the  head ,  loss  of  appetite,  and  insufficient  sleep. 

2.  The  stage  of  exaltation.  The  disturbances  of  the  initial 
stage  disappear  after  a  week  or  two,  but  the  sleep  remains  poor 
or  defective.  The  associations  succeed  each  other  rapidly,  and 
freed  from  the  normal  inhibition,  ideas  come  to  the  patient 
abundantly  and  without  exertion;  writing  is  easy  for  him,  wit 
and  poignancy  bubble  forth  involuntarily.  The  free  play  of 
ideas  makes  it  easy  for  the  patient  to  make  great  plans  for  the 
future,  to  enter  into  new  undertakings,  and  ideas  of  overesti- 
mation  are  develoj^ed  with  the  disappearance  of  former  men- 
tal restraint.  Corresponding  to  this,  his  frame  of  mind  is  full 
of  hope,  joyful,  he  jests  freely  with  others,  and  from  his  happy 
disposition  there  develops  a  great  inclination  to  amuse  himself, 
to  seek  barrooms,  theaters,  public  houses.  The  lack  of  inhibi- 
tion makes  the  maniacs  in  this  stage  very  disagreeable  inmates 
for  those  around  them  in  an  institution,  from  the  recklessness  of 


^Derived  from     fiavia,     meaning  frenzy — •  fxavlKo^,     raving.     Mendel, 
;Monogi-aph.     Vienna  and  Leipzig,  ISSl. 


The  Functional  Psychoses:  Mania.  181 

tlieir  Iroatineiit  ol  others,  and  the  e-\posurc  of  their  weaknesses 
uicl  irregularities.  The  heightened  motor  excitability  shows 
itself  in  their  bright,  sj^arkling,  but  restless  e^'es,  in  a 
lively  play  of  gestures,  in  the  tireless  movements  of  the  fingers 
and  hands  in  severer  grades,  by  their  propensity  to  play  the 
Aagabond. 

The  entire  condition  is  similar  in  the  milder  grades  to  that 
of  drunkenness,  with    which  it  is  often  confounded. 

In  its  further  course  the  accelerated  efflux  of  ideas  reaches 
to  the  flight  of  ideas  ;^  the  patient  changes  from  hundreds  into 
thousands;  the  coming  idea  does  not  reach  its  culmination  be- 
fore a  new  one  comes  into  the  consciousness,  thereby  causing 
the  state  of  maniacal  confusion.  It  is  possible,  however,  to 
hold  the  patients  even  in  this  state,  and  for  them  to  report  with 
sufficient  accuracy  as  to  their  situation,  person,  and  wishes. 

3.  The  stage  of  frenzy.  The  exaltation  rises  to  raving, 
the  patients  scream,  sing,  dance,  break  windows  and  doors,  tear 
their  clothing — and  although  a  part  of  these  violent  actions 
are  called  forth  by  resistance  to  the  limitation  of  their  freedom, 
others  are  wholly  the  product  of  the  heightened  excitability  of 
the  psycho-motor  regions.  Megalomaniacal  ideas  are  mostly 
recognized  in  their  tumultuous  speech.  Finally,  the  patient 
becomes,  in  consequence  of  constant  outcry  and  screaming  day 
and  night,  hoarse  and  scarcely  comprehensible.  The  dullness 
of  their  sensory  feelings  is  shown  in  their  insensibility  to  heat 
and  cold,  their  defective  need  of  food  and  drink,  the  absence 
of  fatigue,  which  enables  them  to  rave  for  days  or  Aveeks  without 
a  pause. 

4.  The  stage  of  decline.  The  restlessness  decreases;  above 
all,  sleep  returns  for  some  hours;  the  sense  deceptions,  which 
were  present  in  the  third  stage,  fade  away,  the  patient  gradually 
passes  over  into  convalescence,  quite  often  so  that  a  certain 
slight  depression,  a  foolish  loquacity  (moria)  forms  the- transi- 
tion. If  recovery  does  not  follow,  a  chronic  condition  of  mania 
with  weakening  of  the  mental  powers  may  develop,  or  death 
comes  in  the  stage  of  frenzy  by  exhaustion  or  complication  with 


'■Ascliaffcnberg.     Experimentelle  Stndien  iieber  Associationen.     TIT. 
Theil.    Ideenflucht  aus  Kraepelin's  Physiologische  Arbeiten  IV.,  2,  1902. 


182  Special  Psychiatry. 


other  diseases  (pneumonia),  or  in  consequence  of  injuries  (with 
septicemia). 

Sometimes  after  the  decadence  of  the  maniacal  excitement 
a  melancholia  develoiDs,  and  a  definite  recovery  first  appears  after 
the  end  of  this  without  further  development  of  a  circular 
psychosis. 

Varieties  of  Mania. 

1.  Rypomania  (]\Iendel),  the  mildest  degree  of  mania. 
The  disease  remains  stationary  at  the  summit  of  a  medium 
degree  of  exaltation,  where  a  certain  self-control  is  still  present, 
which  allows  the  patient  to  appear  transitorily  calm  and  rea- 
sonable. Sometimes  the  accelerated  efflux  of  the  ideas  and  the 
mental  change  in  the  individual  are  only  recognized  by  those 
who  make  a  comparison  of  his  previous  normal  condition  to 
that  in  which  they  find  him  now.  Many  of  these  cases  have 
been  described  as  reasoning  insanity  or  mania  without  delirium. 

2.  Recurrent  mania  (Wittkowski),  two  attacks  of  mania 
separated  by  an  interval.  , 

3.  Mania  Gravis.  In  the  raving  stage  of  a  mania  in  which 
the  disease  comes  on  after  a  brief  period  of  development,  spasms 
appear  (gnashing  of  the  teeth,  twitchings  in  the  face),  A  con- 
tinuous fever  develops,  with  lively. acceleration  of  the  pulse,  the 
temperature  rises  to  106°  F.  and  higher,  death  ensues  through 
collapse.  TTe  have  here  a  complication  of  mania  which,  as  a 
rule,  arises  by  infection  followed  by  septicemia  after  a  trauma, 
received  during  the  state  of  raving.  Some  of  the  cases  of  acute 
delirium  belong  here. 

4.  Periodical  mania.  The  previously  described  type  of 
mania  may  appear  periodically.  The  development  of  the  attacks 
is  usually  very  rapid.  After  short  states  of  anxiety,  which  some- 
times rise  to  precordial  anxiety,  after  neuralgifonn  pains — 
sometimes  in  limited  nerve  regions — the  attack  develops  in  a  few 
da3'S  with  insomnia  and  soon  rises  to  its  full  height.  It  may 
show  the  t}'pe  of  h}'pomania,  that  of  t^'pical  mania,  also  with 
heightening  to  frenzy.  If  the  single  attacks  are  similar  in  their 
nature  and  intensity,  even  to  the  slightest  particulars  (photo- 
graphic faithfulness),  nevertheless  attacks  with  essentially  dif- 
ferent types  of  the  disease  may  appear  between  these  at  intervals. 


The  Functional  I'sijclioses:  Mania.  183 


Generally  the  interval  is  quite  long  at  the  time  of  the  first  devel- 
opment of  the  periodicity,  but  gradually  the  intervals  become 
shorter  and  lose  in  purity. 

Special  Symptomatology. 

1.  Anomalies  of  the  psychic  functions. 

Hallucinations  are  prominently  present  only  in  raving 
states,  and  then  especially  in  the  visual  sense;  illusions,  on  the 
contrary,  especially  in  the  sense  of  vision,  are  frequent  in  the 
stage  of  exaltation.  The  hallucinations  themselves  show  a 
great  motility  and  an  easy  changeability.  Hallucinations  of 
taste  and  smell  are  rare  (in  the  stage  of  frenzy). 

The  feeling  of  disease  is  as  a  rule  wanting  or  only  appears 
at  intervals  transitorily. 

The  fact  that  during  the  pathological  condition  bodily  in- 
firmities which  had  been  previously  present  are  not  felt  (corti- 
cal anesthesia  of  the  coenesthetic  and  of  the  kinesthetic  and  tem- 
perature senses,  feelings  of  hunger  and  thirst)  often  cause  the 
patient  to  say  that  he  has  never  felt  so  well  in  his  life. 

The  heightening  of  the  sexual  impulse  in  typical  mania 
and  in  hypomania  is  connected  Avith  this  feeling  of  pleasure 
which  expresses  itself  in  onanism,  satyriasis,  njmiphomania,  in 
equivocal  or  immodest  expressions  in  good  society,  in  the  pres- 
ence of  women,  and  similar  indecent  offenses. 

The  feelings  of  judgment,  especially  the  ethical,  are  gen- 
erally weakened  or  have  disappeared. 

Maniacs  undress  themselves  completely  without  feeling 
shame,  young  girls  of  the  best  society  utter  expressions  which 
one  would  never  think  had  come  to  their  ears.  Lese  majeste, 
thefts,  and  the  like  in  the  maniacal  condition  rest  on  the  loss 
of  such  feelings. 

The  anomaly  of  thought  has  essentially  in  mania  an  accel- 
eration of  the  efflux  of  the  ideas  for  its  point  of  departure;  it 
leads  direct  to  the  flight  of  ideas  (see  Aschaffenburg,  I.e.  139). 
But  what  the  associations  gain  in  rapidity  tlicy  lose  in  depth  and 
acuteness.  The  rapidity  pushes  aside  or  renders  impossible 
the  intervention  of  contrasting  ideas,  and  thereby  criticism.  On 
this  defect,  also,  rests  the  fact  that  such  patients  identify  simi- 
larities from  unimportant  indications  (delirium  palingnosticum). 


184  Special  Psycliiatry. 


From  the  rapidity  with  which  the  associations  are  perfected^  the 
laws  governing  them  are  violated,  the  connection  of  ideas  does 
not  take  place  on  a  real  basis,  but  after  external  signs,  often  from 
the  soimd  of  syllables  and  words  (alliteration,  assonance,  asso- 
ciation of  sounds).  Speech  rises  from  i)ol3'phrasia  to  a  senseless 
delirium  of  the  tongue.  The  tongue  cannot  follow  the  supera- 
bundance of  ideas,  words  are  swallowed,  and  in  consequence  the 
patient  seems  to  be  more  confused  than  he  really  is. 

Maniacal  confusion  is  characterized  not  only  by  the  pa- 
tient's breaking  away  from  the  most  senseless  discourse,  as 
remarked  above,  and  then  being  in  a  condition  to  answer  intelli- 
gently, but  also  to  recite  without  ulterior  motive  a  long  poem 
without  mistake,  or  to  give  a  detailed  narrative  of  his  life. 

The  delusions  which  are  of  expansive  nature  are  in  the 
beginning  essentially  ideas  of  the  overestimation  of  one's  self 
(mania  ambitiosa),  and  rise  later  to  megalomaniacal  ideas  with- 
out reaching  the  nonsensical  delusions  of  grandeur  so  charac- 
teristic of  paresis. 

The  memory  in  many  cases  shows  extreme  retentiveness 
(hypermnesia),  so  that  the  patient  can  reproduce  events  from 
his  earlier  life  which  he  would  be  unable  to  do  normally. 

If  in  general  the  disposition  of  the  |)atients,  corresponding 
to  the  unrestrained  feelings,  is  serene  and  joyful,  it  may  also 
be,  on  the  other  hand,  irritable  and  irascible  contemporaneously, 
especially  if  the)^  cannot  have  their  way.  One  often  observes 
a  rapid  change  of  the  disposition,  immoderate  laughter  and  loud 
weeping  alternating. 

In  the  somatic  functions  the  most  striking  are  the  height- 
ening of  the  motility,  the  unrest  of  the  whole  body,  the  height- 
ened powers,  which  should  not  be  ascribed  to  an  actual  increase 
of  strength,  but  which  only  result  from  the  absence  of  the  nor- 
mal feeling  of  fatigue  (see  the  maniacal  expression  of  the  face). 

The  hody  iveiglit  diminishes  considerably,  increases  with 
the  beginning  of  convalescence,  but  is  wont  to  increase  no  further 
with  perfect  recovery,  sometimes  even  decreases.  In  periodical 
mania  one  may  sometimes  diagnose  the  approach  of  the  attack 
by  the  rapid  decrease  in  the  weight  (Fuerstner).  The  urine 
shows  a  decrease  in  the  phosphoric  acid. 

Etiology, — Mania  is  a  rare  mental  disease.     It  takes  the 


The  Functional  Psychoses:  Mania.  185 

last  place  in  the  functional  psychoses  beside  acute  dementia  in 
point  of  frequency.  It  is  especially  observed  at  from  fifteen  to 
twenty-five  years,  equally  frequent  in  both  sexes.  It  may  also 
appear  in  children  and  old  people. 

In  regard  to  the  hereditary  basis,  it  has  the  same  proclivities 
as  the  other  functional  psychoses.  Traumata,  cardiac  defect 
(mania  cardiaca)  may  be  emphasized  among  its  special  causes.  ^ 

Why  mania  appears  only  once  in  a  lifetime  in  one  case, 
never  to  return,  and  in  a  great  number  of  other  cases  the  disease 
takes  a  periodic  course,  is  inexplicable. 

The  outbreah  of  mania  is  seldom  sudden,  except  the  at- 
tacks of  periodic  mania,  which  sometimes  develop  rapidly.  The 
course  of  the  disease  shows  numerous  remissions  and  exacerba- 
tions, both  in  its  development  as  well  as  in  its  decadence.  The 
duration  varies  between  three  and  nine  months.  For  transitory 
mania,  see  transitory  mental  disturbances. 

The  results  are: — 

1.  Recovery,  which  is  reached  in  four-fifths  of  all  the  cases. 

2.  Tendency  of  the  disease  to  return.  Eelapses  may  ap- 
pear in  the  same  clinical  type  or  as  melancholia  (which  see). 

3.  Imperfect  recovery  (recovery  with  a  defect),  where  a 
certain  change  in  the  patient,  a  certain  greater  irritability,  and, 
on  the  other  hand,  a  certain  lack  of  energy  with  a  slight  weak- 
ening of  the  mental  powers  remain. 

4.  Terminal  dementia.  While  the  delusions  of  raving  be- 
come less,  the  patient  becomes  calmer,  but  the  mental  power  and 
with  it  the  memory  generally  remains  considerably  impaired. 
In  many  cases  there  remains  also  in  this  chronic  condition  a 
certain  inclination  to  heightened  excitement  and  to  maniacal 
exaltation  (chronic  mania). 

5.  Death,  which  may  be  conditioned,  first,  by  diseases  from 
which  the  mania  has  arisen,  as,  e.g.,  by  heart  disease;  second,  by 
wounds  which  the  patient  has  inflicted  upon  himself  while 
raving  or  has  sufl'ered  from  others,  with  pyemia  or  septicemia 
following;  third,  by  exliaiistion. 

Diagnosis. — The  essential  characteristics  of  mania  are:  1, 

the  accelerated  efflux  of  the  ideas;  2,  the  motor  unrest;  3,  the 

absence  of  symptoms  which  confirm  an  organic  disease  of  the 
brain. 


186  Special  Psychiatry. 


A  differential  diagnosis  must  be  made  from: — 

1.  The  maniacal  stage  of  paresis.  Here  the  disturbances 
of  speech,  the  reflex  rigidity  of  the  pupils,  changes  in  the  tendon 
reflexes,  and,  generally,  a  settled  condition  of  mental  weakness 
are  of  decisive  significance  against  the  assumption  of  a  mania. 

2.  Maniacal  excitement  in  intoxication.  Here  the  anam- 
nesia  and  the  special  changes,  which  the  various  toxins  in  the 
body  call  forth,  are  decisive. 

3.  Eaving  states  in  hystericals  and  epileptics,  which  are  dis- 
tinguished by  their  acute  and  peracute  beginning,  generally  in 
connection  with  seizures. 

4.  Delirium  hallucinatorium    (which  see). 

"Whether  a  maniacal  excitement  belongs  to  a  periodic  mania 
or  to  a  circular  psychosis  can  be  determined  with  certainty  onh' 
by  the  ananmesia  or  its  further  course.  In  general,  a  remark- 
ably sudden  onset,  with  precordial  anxiety  or  neuralgiform 
pains,  a  rapid  rise  to  the  height  of  the  disease  though  running 
a  mild  course,  an  exaltation  not  mounting  to  raving,  lack  of 
confusion,  and  a  ver\-  considerable  mental  deviation  even  with 
great  excitement  speaks  for  the  periodic  or  circular  form. 

Prognosis. — The  prognosis  of  mania  may  be  called  favor- 
able. It  is  unfavorable  in  periodic  mania,  yet  here  remissions 
appear  which  may  be  of  so  long  duration  that  one  might  well 
assume  recovery.  Sudden  cessation  of  the  maniacal  excitement 
is  an  unfavorable  symptom  prognostically ;  it  points  to  a  circu- 
lar or  periodical  course. 

Treatment. — The  diagnosis  of  "mania'*  should,  as  a  rule, 
be  followed  by  the  commitment  of  the  patient  to  an  institution, 
both  for  his  own  interest  and  that  of  the  community.  If  he  is 
left  to  himself  he  will  aggravate  the  disease  by  misuse  of  alco- 
holic drinks  and  a  dissipated  life,  and  will  squander  his  means 
by  needless  expenditures.  B}-  the  recklessness  of  his  conduct 
he  will  become  dangerous  to  others.  If  he  is  in  an  insti!nition 
the  expectant  method  of  treatment  is  to  be  recommended.  Eest 
in  bed  and  wet  packs  will  generally  be  sufficient;  if  raving  comes 
on,  isolation  in  a  dark  room  will  be  required ;  transiently  also  in 
continuous  raving  excitement  the  emiDlo^Toent  of  chloral  hydrate 
and  duboisin  cannot  be  dispensed  with.  Opiates  seldom  exer- 
cise a  really  soothing  influence. 


The  Functional  Psychoses:  21  elancholia.  187 

In  periodical  mania  one  may  try  bromide  of  potash  in  large 
doses,  8  to  10  grams  daily.  In  sporadic  cases  I  have  seen  results 
from  subcutaneous  injections  of  ergotin.  Atropin  injections  are 
recommended  by  Hitzig  in  the  intervals  between  the  attacks  in 
doses  of  0.0001,  0.0002  to  0.0003. 

3.  Melancholia.! 

Melancholia  is  a  psychosis  whose  basis  and  point  of  depart- 
ure lie  in  a  pathologically  heightened  painful  excitation  of  the 
psyche. 

(a)   Simple  Melancholia.    Hypomelancliolia   (Ziehen). 

A  condition  of  sorrow  appears,  with  or  without  any  consid- 
erable cause  founded  upon  the  external  relations.  Past,  pres- 
ent, and  future  appear  to  the  patient  in  gloomy  colors. 

One  of  my  patients  designated  his  condition  as  identical 
with  that  described  in  Wilhelm  Meister :  He  had  not  taken  the 
least  interest  for  years  in  what  was  foreign  to  himself,  had 
almost  observed  nothing;  simply  self-absorbed,  he  had  perceived 
his  vacant,  empty  Ego,  which  seemed  to  him  to  be  an  immeas- 
urable abyss.  How  touching  it  was  when  he  spoke  of  this  sor- 
rowful condition !  "I  see  nothing  before  me,  nothing  behind 
me,"  he  exclaimed,  'Taut  an  eternal  night,  in  which  I  am  in  the 
most  horrible  solitude;  no  feeling  remains  except  the  feeling  of 
my  sin,  which  is  only  perceived  as  a  distant,  formless  specter 
behind  me.  Yet  there  is  no  height,  no  depth,  no  forward,  no 
backward;  no  word  expresses  this  condition,  which  is  always 
the  same." 

This  sorrowful  disposition  takes  from  the  patient  the  possi- 
bility of  ordinary  activity,  and  this  idleness  is  the  cause  of  new 
reproaches  against  himself.  The  patient  feels  himself  ob- 
structed, and  by  this  even  his  thought  is  retarded;  it  is  difficult 
for  him  to  make  a  resolution,  to  rouse  himself;  coincidently, 
there  exists,  as  a  rule,  obstinate  insomnia,  lack  of  appetite,  and 
marked  intestinal  inactivity.  In  some  cases  the  moral  qualities 
of  the  patient  occupy  his  mind  chiefly.  What  he  has  done  and 
what  he  has  not  done  cause  him  anxiety  about  the  performance 


'  From  //Aa!,    black,  and   x^'^°^)  S^l^- 


188  Special  rsycliiairy. 


of  liis  duty.  In  other  cases^  his  physical  condition  and  what  it 
will  be  in  the  future  form  the  essence  of  the  anxiety;  hypochon- 
drie  complaints^,  fear  of  insanity,  of  tabes  dorsalis,  and  of 
other  diseases  occupy  him  entirely.  With  this,  self-reproaches 
are  not  wanting:  "If  I  had  done  otherwise,  if  I  had  been  more 
careful,  it  would  have  been  difEerent." 

Such  states  may  last  from  three  to  five  months,  sometimes 
longer;  show  many  variations  in  their  intensity,  are  generally 
worse  in  the  morning  than  in  the  evening,  and  gradually  lead 
to  recovery.  They  have  a  great  tendency  to  relapses,  and  also 
appear  periodically. 

(b)   Typical  Melancholia. 

The  pathological  change  of  the  feelings  may  affect:  1,  the 
sensorial  feelings ;  2,  the  moral  feelings ;  3,  both ;  and  we  distin- 
guish, therefore,  a  hypochondrie  melancholia,  a  moral  mel- 
ancholia, and  a  general  melancholia. 

1.  Hypochondrie   Melancholia. 

(a)  Stage  of  depression.  Fear  and  anxiety  for  the  present 
and  future  condition  of  the  body  and  spirit  dominate,  as  has 
been  mentioned  in  hypomelancholia.  In  this  stage  determined 
self-accusations  are  generally  observed. 

(&)  Melancholic  stage.  The  patient  no  longer  controls 
himself  in  expressing  his  hypochondrie  complaints,  but,  Avith 
vivid  self -accusations  of  preceding  onanism  and  syphilis,  of  dis- 
sipated living,  and  other  excesses,  the  hypochondrie  feelings 
have  become  excessively  fortified  and  encouraged  up  to  a  hypo- 
chondrie mania.  He  lias  perceived  everywhere  the  symptoms 
of  the  destruction  of  his  body  by  syphilis,  his  entrails  are  rotten, 
and  the  like. 

The  further  course  is  correspondingly  the  same  for  the 
various  forms. 

2.  Moral  Melancholia. 

(a)   The  stage  of  depression.     This  stage  shows  essentially 

the  symptoms  of  a  hypomelancholia,  general  discontent,  vague 

fear,  retardation  of  the  efflux  of  ideas,  thoughts  of  death,  and 

also  ideas  of  self-destruction.     At  times  during  this  stage,  sud- 


The  Functional  Psychoses:  Melancholia.  189 

den  heightenings  of  anxiety  are  observed,  -wliicb  manifest  them- 
selves in  raptus  melancholicus. 

(h)  Stage  of  melancboly.  Tbe  patient  bas  discovered  tbe 
cause  of  bis  sorrow,  be  accuses  himself  of  having  lied,  of  having 
perjured  himself,  be  bas  not  done  his  duty  towards  God  or  man 
(delusion  of  transgression).  Xot  only  will  he  meet  divine  pun- 
ishment after  death,  but  be  will  be  imprisoned  here  for  his  sins ; 
he  bears  tbe  police  coming,  bears  tbe  clanking  of  the  chains. 
In  contrast  to  the  complaints  made  in  Iwpochondric  melan- 
cholia, these  patients  consider  it  foolish  if  tbe  physician  wishes 
to  see  tbe  tongue,  if  be  feels  tbe  pulse,  since  in  general  they  can- 
not suffer  from  physical  disturbances.  Tbe  external  behavior 
of  the  patients  in  this  stage  is  either  calm,  perfectly  quiet,  or 
filled  only  with  uniform  whimpering  and  sighing  (passive  mel- 
ancholia), or  it  is  expressed  in  loud  shrieks,  lamentations,  con- 
stant groaning,  amid  which  they  may  attempt  violent  actions 
against  themselves,  tearing  their  clothes,  tearing  out  their  hair, 
and  similar  acts  (active  or  agitated  melancholia).  At  the  height 
of  this  sorrowful  disposition,  which  begins  with  anxiety,  there 
is  in  a  nunil)er  of  cases  an  anxious  raving;  in  other  cases,  an 
anxious  stupor. 

3.  General  Melancholia. 

Tbe  pathological  ideas  of  hj^pocbondrie  melancholia  and 
moral  melancholia  are  associated.  Sometimes  the  bj-pocbon- 
dric  ideas  come  first,  while  tbe  delusion  of  transgression  fol- 
lows later. 

The  disease,  the  destruction  of  tbe  internal  organs,  is  the 
wrath  of  God  for  all  sins  committed.  In  other  cases  the  delu- 
sion of  transgression  appears  first,  after  which  the  hypocbon- 
dric  delusions  follow,  since  God  punishes  them  for  sin.  In 
other  cases  both  series  of  ideas  develop  contemporaneously  in 
intimate  connection. 

Tbe  conditions  descril)ed  in  tbe  three  different  forms  may 
gradually,  with  attenuation  of  the  s3'mptoms,  pass  over  into 
recovery,  sometimes  with  a  transition  stage  in  which  a  pro- 
nounced homesickness  develops,  especially  if  the  patient  is  far 
from  home.  In  other  cases,  with  the  fading  out  of  tbe  delusions 
and  sense  deceptions,  a  state  of  mental  weakness  may  develop 


190  Special  Psychiatry. 


in  which  the  earlier  depressive  state  is  still  reflected  Tvith  its 
pathological  ideas.  Finally,  death  comes  hy  suicide  in  a  certain 
numher  of  cases;  in  others,  hy  exhaustion,  especially  in  conse- 
quence of  sitophohia ;  in  others,  hy  diseases  appearing  in  the 
internal  organs,  among  which  tuberculosis  is  most  frequent. 

Under  the  influence  of  jDubert}',  sometimes  from  other  un- 
known causes,  the  course  of  melancholia,  especially  its  Iiypochon- 
dric  type,  may  he  peculiar  and  quickly  pass  into  dementia. 
Here  belong  a  considerable  number  of  the  cases  of  hebephrenia 
and  katatonia,  whose  frequent  result  is  dementia  prgecox.  In 
this,  sometimes,  the  suffering  and  persecuted  heroes  of  whom 
the  patient  has  read  in  stories  and  romances,  and  with  whom 
he  childishly  identifies  himself,  play  prominent  roles. 

Special  Symptomatology. 

1.  Illusions  and  hallucinations.  These  are  absolutely  of 
an  anxious  nature  in  melancholia,  frequently  blaming  and  threat- 
ening the  j)atient,  and  have,  as  a  rule,  a  more  or  less  fixed  char- 
acter. Hallucinations  are  wanting  in  the  dej)ressiYe  stage,  but 
are  abundant  in  the  melancholic  stage.  The  patients  see  the 
fire  in  which  they  are  to  be  burned,  the  devil  who  will  become 
their  master.  They  hear  the  lamentations  of  their  children,  the 
steps  of  policemen  who  wish  to  take  them  into  custodA^;  they 
smell  and  taste  poisonous  substances,  which  are  destined  for 
their  destruction  as  a  punishment  for  their  evil  deeds.  In  the 
hypochondric  form  the  hallucinations  of  the  ccenesthetic 
sense,  especially,  portra}"  the  clinical  picture  of  the  melan- 
cholic stage.  The  patients  feel  that  their  heads  are  of  glass, 
their  arms  of  wood,  their  intestines  rotten,  their  stomachs  sunken 
in,  the  anus  closed,  the  sexual  organs  withered  or  drawn  up  into 
the  abdomen. 

2.  The  retardation  in  the  course  of  ideas  is  characteristic 
of  melancholia.  The  entire  psychic  condition  becomes  monot- 
onous thereby.  The  delusions  are  of  a  depressive  nature.  The}- 
are  partially  connected  with  the  momentary  hallucinations,  and 
interpret  them  anew  according  to  the  present  occurrences.  But, 
as  a  rule,  the  past  also  is  newly  interpreted  in  accordance  with 
the  existing  depressive  ideation,  especially  in  the  sense  of  self- 
accusation.      In    hyjDochondric    melancholia    the    ideas    are    di- 


The  Functional  Psychoses:  Melancholia.  191 

rected  to  the  sensation  of  tlie  jDathological  change  or  annihiUi- 
tion  of  the  organs;  in  the  moral  form,  the  patient  believes  him- 
self materially  ruined  and  morally  dishonored.  With  these  de- 
pressive ideas  self-accusation  and  the  delusion  of  transgression 
stand  in  intimate  association.  Ideas  of  persecution  develop  in 
consequence.  The  patient  considers  the  persecution  a  just  pun- 
ishment for  his  actions. 

As  a  result  of  the  insane  comprehension  of  the  Ego,  arises 
the  delusion  of  poverty,  the  delusion  of  being  deserted,  which 
is  observed  very  frequently  in  the  senile  form  of  melancholia. 

In  many  cases  of  melancholia,  a  delusion  of  negation  arises. 
The  patient  has  no  stomach,  no  rectum,  no  blood  left,  he  does 
not  exist;  besides  this,  no  man  exists,  there  are  no  houses  left. 
All  these  sense  deceptions  and  delusions  heighten  the  fear  and 
anxiety  originally  present.  Sometimes  the  excesses  of  the  mel- 
ancholiacs  are  expressed  as  micromania,  "they  wish  to  cut  off 
each  of  my  members  separately,"  "I  have  committed  all  the  sins 
in  the  world,"  and  so  forth. 

3.  The  anomalies  of  the  feelings,  which  represent  the  pri- 
mary affection  in  this  disease,  sometimes  ajDpear  in  the  later 
stage  of  the  disease,  so  that,  with  the  psychic  pain  present,  there 
is  an  anesthesia  of  the  feelings  in  regard  to  those  persons  who 
at  first  were  best  able  to  calm  them  (anesthesia  dolorosa). 

4.  The  memory  is  not  destroyed,  but  the  reproduction  is 
slow,  as  Avell  as  every  other  psychic  activity.  With  rare  excep- 
tion there  is  a  good  recollection  for  what  passes  during  the  dis- 
ease. 

5.  The  speech,  like  thought  and  action,  is  slow  and  slug- 
gish. The  lips  move  very  little,  the  utterance  is  scarcely  audible. 
In  other  cases  only  broken  sentences  are  uttered,  interrupted  by 
sighs  and  groans.  Sometimes  the  patient  is  wholly  speechless, 
either  on  account  of  anxiety  or  incapability  of  associating  the 
words,  or  because  delusions  or  sense  deceptions,  or  both,  prohibit 
speech. 

G.  In  regard  to  action,  negativism  and  passive  resistance 
are  opposed  to  everything  the  patient  essays  to  do.  Sitophobia 
may  sometimes  be  ascribed  to  this  condition.  One  should  not 
be  deceived  by  the  calmness  of  the  patient.  It  nuiy  he  that  he 
has  not  made  a  movement  for  a  montli.  Init  Uiin  in  bed  all  the 


192  Special  Psychiatry. 


time,  yet  he  may  rise  siTcldenly  when  unwatched  and  commit 
suicide  with  the  greatest  energy. 

Suicide  plays  the  greatest  part  in  the  most  diverse  forms  of 
melancholia.  The  impulse  is  sometimes  so  strong  and  so  fills 
the  whole  spiritual  life  that  some  have  spoken  of  a  suicidal  mel- 
ancholia. In  the  same  way  self-mutilation  often  appears  with 
melancholiacs.  (For  the  motives  for  suicide,  see  suicide  under 
results  of  the  psychoses).  In  raptus  melancholicus  violent  ac- 
tions towards  others  are  rare. 

7.  Insomnia,  loss  of  appetite,  and  repugnance  to  nourish- 
ment are  the  most  constant  physical  symptoms.  The  face  shows 
spasmodic  contractions  in  the  superior  facial  region,  while  the 
inferior  facial  region  appears  lax,  the  corners  of  the  mouth 
droop,  the  mouth  is  open  and  saliva  trickles  therefrom,  and  the 
face  is  directed  to  the  ground.  The  tongue  is  only  slightly  pro- 
truded, eating  is  slow,  the  food  or  drink  taken  into  the  mouth 
is  slowly  moved  about  before  swallowed.  The  movements  of  the 
arms  are  labored  and  difficult,  the  patient  takes  short  steps  in 
walking.  The  muscles  often  seem  lax,  sometimes  hypotonic;  in 
other  cases  there  is  abnormal  tension.  With  the -tension  is  con- 
nected quite  often  the  condition  of  flexibilitas  cerea.  In  regard 
to  the  vasomotor  nerves,  it  should  be  mentioned  that  in  melan- 
cholia there  is,  as  a  rule,  an  arterial  hypotension.  There  is  a 
general  feeling  of  coldness,  hands  and  feet  feel  cold  and  show  a 
certain  degree  of  cyanosis.  The  patient  weeps  readily,  usually 
without  tears.  Precordial  anxiety  is  to  be  attributed  to  the  af- 
fection of  the  vasomotor  nerves  which  generally  accompanies 
melancholia  from  i-ts  beginning.  The  state  of  raptus  melancholi- 
cus is  designated  as  an  expression  of  the  precordial  anxiety  with 
a  violent  outwardly  demonstration. 

In  melancholia  the  pulse  is  apt  to  be  small  and  slow,  the 
number  of  respirations  is  diminished,  the  tongue  seems  dry, 
gums  and  lips  are  often  covered  with  fuliginous  fur. 

The  stomach  often  shows  an  excess  of  free  hydrochloric 
acid,  the  urine  'is  diminished  both  in  quantity  and  in  the  solid 
contents.  The  earthy  phosphates  are  increased  in  quantity. 
The  menstruation  frequently  ceases  during  the  disease,  returns 
with  the  beginning  of  convalescence,  but  sometimes  first  reap- 
pears with  recovery.     The  temperature  of  the  body  is  subnormal, 


The  FunclioiKtl  I'sijchoscs:  Melancholia.  193 


sometimes  with  the  type  inverted.  The  weight  of  the  body  in 
melancholia  generally  decreases  very  considerably. 

Etiology. — Of  all  the  functional  psychoses,  except  delirium 
hallucinatorium,  melancholia  is  the  most  frequently  observed. 
It  appears  oftener  in  women  than  in  men.  The  age  of  greatest 
incidence  in  both  men  and  women  is  between  twenty  and  thirty 
years;  then  in  women  forty-five  to  fifty,  and  fifty  to  sixty  in 
men.  Puberty  often  disposes  to  melancholia  and  is  frequently, 
also,  the  cause  of  an  abnormally  unfavorable  course  of  the  dis- 
ease. The  same  is  true  of  the  beginning  of  old  age,  while  senile 
melancholia  often  passes  over  into  senile  dementia.  Psychic 
depressive  influences  play  a  considerable  part  among  the  direct 
causes,  but  those  which  at  first  cause  joy  may  be  injurious  in 
the  predisposed.  Thus  it  sometimes  happens  that  women  en- 
gaged to  be  married  have  outbreaks  of  melancholia,  and  lament 
that  they  will  be  unable  to  fulfill  marital  duties  because  they 
do  not  love  their  future  husbands.  In  men,  especially,  under 
such  conditions  there  are  melancholic  complaints  over  youthful 
sins,  hypochondric  anxiety  whether  they  are  potent,  and  the 
like.  In  the  same  way,  melancholia  quite  often  develops  soon 
after  the  wedding,  even  on  the  wedding  night.  Puerperium, 
disturbances  of  the  abdominal  organs,  onanism,  spermatorrhea, 
with  their  weakening  influences,  may  become  the  causes  of 
melancholia. 

The  outhreah  of  the  disease  is  generally  gradual,  very  ex- 
ceptionally sudden.  The  disease  follows  the  same  gradual 
course,  with  exacerbations  and  remissions,  in  the  process  of 
recovery.  There  is  also  a  periodic  melancholia^  which  appears 
frequently  in  the  form  of  simple  melancholia  and  returns  in 
many  patients  each  spring  or  fall.  Many  of  the  cases  which  are 
described  as  periodic  manias  show  the  symptoms  of  a  melan- 
cholia on  closer  analysis. 

Remittent  melancholia  is  a  chronic  melancholia  of  slight 
intensity  of  symptoms,  with  renewed  severe  attacks  of  the  dis- 
ease at  intervals. 

The  duration  of  the  disease  is  seldom  under  three  or  four 
months;  developed  forms  do  not  reach  recovery  till  after  nine 
months  or  one  year.  Some  cases  last  several  years  and  then 
are  cured. 

13 


194  Special  Psychiatry. 


Results: — 

1.  EecoTe^3^  Simple  melancholia,  as  a  rule,  terminates  in 
recovery,  but  often  there  are  relapses.  T3-pical  melancholia 
is  cured  in  about  60  per  cent,  of  all  cases.  Eecovery  is  reached 
gradually;  exceptionally,  very  suddenly.  Eelapses  of  a  psychic 
disease,  sometimes  after  ten  years  and  later,  are  frequent;  they 
generally  f oUo^v  under  the  same  clinical  t^'pe ;  sometimes,  also,  as 
mania. 

2.  The  transition  to  a  secondary  state — chronic  melancholia, 
terminal  dementia. 

3.  Death,  especially  by  suicide;  exhaustion  or  tuberculosis. 
Diagnosis. — To   the   diagnosis   of   melancholia   belong:     1. 

Depressive  disposition.  2.  Ps3'chic  inhibition.  3.  Self-accusa- 
tion. 4.  Absence  of  all  symptoms  -vrliich  point  to  a  complicated 
psychosis,  to  an  intoxication  or  an  organic  psychosis. 

For  the  differential  diagnosis  there  should  be  considered : — 

1.  Paresis.  In  its  depressive  stage  or  depressive  type  the 
portrait  of  the  mental  condition  may  be  similar  to  that  of  mel- 
ancholia. Disturbances  of  speech,  condition  of  the  pupillary 
reflexes,  and  paralj'tic  attacks  confirm  the  diagnosis. 

2.  Paranoia.  The  paranoiac  may  express  his  delusions 
in  the  same  manner  as  the  melancholiac.  But  the  paranoiac  be- 
lieves that  he  is  persecuted  because  certain  men  are  hostile  with- 
out his  having  given  them  adequate  cause,  or  because  they  fear 
him.  He  opposes  his  persecutors.  The  melancholiac  considers 
the  persecutions  justified,  often,  it  may  be,  too  cruel,  but  some- 
times not  severe  enough  for  his  misdeeds. 

3.  Delirium  hallucinatorium  (which  see). 

4.  Wliether  the  melancholic  condition  is  a  partial  phenom- 
enon of  a  circular  psychosis,  or  whether  it  belongs  to  a  periodic 
melancholia,  can  be  absolutely  determined  only  from  the  anam- 
nesia  or  the  course.  Very  mild  melancholiacs  awaken  the  sus- 
picion of  periodicity. 

5.  Melancholiacs  dissimulate  quite  often,  especiallv  in  order 
to  deceive  those  around  them,  to  avoid  the  strict  watch,  or  to 
escape  from  the  institution  and  then  to  commit  suicide.  An 
accurate  examination,  and  especially  watching  the  patient  during 
the  night,  will  guard  against  such  deception. 


The  Fundional  Psychoses:  Melancholia.  195 

Prognosi^i. — The  prognosis  is  favorable  in  simple  melan- 
cholia, although  relapses  and  periodicity  are  to  be  feared.  Ac- 
cording to  the  percentage  of  recoveries  given,  the  prognosis  of 
typical  melancholia  is  not  unfavorable.  It  grows  considerably 
worse  if  the  melancholia  takes  the  course  of  a  katatonia. 

Treatment. — The  most  vigilant  watching  of  the  patient  is 
necessary  as  the  first  step  in  the  treatment  of  melancholia.  If 
this  is  possible  by  the  favorable  conditions  surrounding  the 
home,  one  may  treat  the  melancholiac  there,  assigning  him  an 
isolated  room  and  letting  him  lie  in  bed  suitably  guarded.  These 
conditions  do  not  exist  in  the  homes  of  the  masses,  and  on  that 
account  the  patient  should  be  taken  to  an  institution.  But 
whether  he  is  at  home  or  in  an  institution,  the  first  care  should 
be  to  cheer  him  up,  since,  where  the  diagnosis  is  "melancholia," 
there  is  a  suspicion  of  self-destruction,  even  if  the  patient  has 
expressed  nothing  of  this  kind,  and,  consequently,  the  most  con- 
stant watching  is  required,  and  the  patient  must  not  be  left  alone 
for  even  the  so-called  "instant." 

In  hypochondric  melancholia  the  most  accurate  examina- 
tion of  every  organ  must  precede  any  line  of  treatment,  and  due 
consideration  of  pathological  changes  of  the  organs  should  be 
made  an  essential  part  of  the  treatment. 

Moreover,  rest  in  bed,  good  nutrition,  packs,  protracted 
baths,  are  powerful  remedies  in  all  cases. 

For  a  long  time  the  opium  treatment  in  melancholia  has 
been  in  good  repute  (Ziehen.  Therapeutische  Monatshefte,  1889). 
One  may  even  increase  the  dose  gradually  to  1.0  g.  per  day. 
In  other  cases  morphine  injections  act  better,  beginning  with 
0.015  and  increasing  to  0.03,  even  to  0.06,  three  times  daily. 
If  vomiting  takes  place  with  the  morphine  injections,  small  doses 
of  atropin  may  be  added.  With  this  there  should  be  given  with 
each  meal  a  few  drops  of  hydrochloric  acid  to  prevent  the  dimi- 
nution of  the  hydrochloric  acid  secretion  of  the  stomach. 

In  passive  melancholia  sometimes  it  may  be  well  to  use 
spiritus  vini  rarissimus  in  teaspoonful  or  tablespoonful  doses, 
several  times  daily  (Mendel,  Obermeier).  One  may  give  as  a 
hypnotic  trional,  paraldyhyde,  and,  in  very  obstinate  cases, 
chloral  hydrate.  From  the  great  number  of  other  remedies 
which  are  recommended,  as,  e.g.,  digitalis,  phosphorus,  hellebore, 


196  Special  Psychiatry. 


not  much  is  to  be  expected.    One  should  combat  sitophobia  with 
nourishing  clysters  and  the  esophageal  sound. 

Although  dismissal  from  the  institution  should  take  place 
when  the  patient  has  recovered,  and  especially  when  convales- 
cence is  shown  by  a  considerable  permanent  increase  in  the  body- 
weight,  there  are  cases  in  which  melancholiacs,  who  have  very 
pronounced  homesickness,  may  be  sent  home  tentatively  under 
very  strict  surveillance.  In  such  cases  recovery  often  sets  in 
very  suddenly. 


4.    Circular  Psychosis.^ 

In  a  certain  number  of  cases  the  mental  disease  appears 
composed  of  two  contrasting  types  of  conditions,  the  maniacal 
and  depressive.-  Permanent  recovery  may  follow  such  a  dis- 
ease; the  same  tv'pe,  or  only  a  mania  or  melancholia,  may  appear 
in  a  relapse;  it  may  also  appear  as  the  relapse  of  a  mania  or 
melancholia,  a  manic-depressive  insanity. 

Only  those  psychoses  which  show  melancholic  depressions 
and  maniacal  exaltations  in  a  more  or  less  regtilar  interchange 
are  designated  as  circular  psychoses;  furthermore,  as  intermit- 
tent, when  there  is  an  interval  between  the  single  phases  of  the 
disease,  and  as  continuous  if  there  is  no  such  interval.  The  con- 
tinuous form  of  the  disease  often  develops  from  the  intermittent 
in  its  further  course.  One  may  speak  of  cyclothymia  (Hecker) 
where  the  melancholic  and  maniacal  stage  appears  in  the  very 
mildest  form.  For  the  rest,  all  degrees  of  development  of  mania 
and  melancholia  are  shown  in  the  maniacal  and  melancholic 
stage  of  circular  psychosis. 

In  the  majoritj^  of  cases  the  circle  begins  with  melancholia, 
after  it  has  sometimes  been  preceded  by  an  aura  with  pares- 
thesias, gastric  disturbances,  insomnia,  sometimes  sporadic 
trophic  disturbances,  as,  e.g.,  herpes.  In  other  cases  the  aura 
consists  of  a  great  desire  to  sleep,  general  dejDression,  palpitation 


^  Hoche.  Ueber  die  leichteren  Formen  period.  Irreseins.  Halle, 
1897.  Pilcz.  Period.  Geistesstorungen.  Jena,  1901.  Ziehen.  Xeu- 
rologisches  Centralblatt,  1896. 

-  Kahlbaum's  psychosis  typica ;  manic-depressive  insanity,  Krae- 
pelin. 


The  Functional  Psychoses:  Circular  Psychosis.         197 

of  the  heart,  pains  in  the  back  and  elsewhere.  The  depressive 
stage  is  generally  strongly  developed,  sometimes  so  strongly  that 
the  maniacal  stage  is  misconceived  as  pathological  and  thought 
of  only  as  a  physiological  reaction,  as  a  removal  of  the  weight 
which  burdened  the  patient  during  the  stage  of  melancholy. 
But  the  manifold  activity,  the  great  agility,  the  inclination  to 
all  kinds  of  undertakings  cannot  be  regarded  as  normal,  because 
the  patient  is  continually  heeding  an  impression  which  flashes 
before  him  at  intervals  and  warns  him  that  he  is  again  to  become 
diseased. 

Besides  this,  there  is  also  regularly  an  abnormal  irritation 
in  this  stage  of  mania.  In  other  cases  the  maniacal  stage  is 
very  clearly  defined,  but  it  very  seldom  rises  to  raving  excite- 
ment. Sometimes  the  change  between  the  various  phases  is 
brought  about  in  a  night.  The  patient  goes  to  bed  depressed, 
with  wrinkled,  careworn  face,  with  his  hair  dry  and  lying  close 
to  his  head;  he  arises  in  the  morning  joyful  and  serene,  with 
glistening  eyes  and  his  hair  in  locks;  he  has  passed  from  the 
melancholic  to  the  maniacal  stage.  In  other  cases  the  transi- 
tion is  completed  with  variations,  so  that  the  opposing  impulses 
obtain  the  mastery  of  the  patient  at  different  times  (mixed 
forms).  Although  the  various  attacks  in  their  further  course 
are  alike  in  duration  and  intensity,  sometimes  even  show  photo- 
graphic faithfulness,  yet,  on  the  other  hand,  the  type  in  the  dif- 
ferent attacks  is  quite  often  very  dissimilar.  Sometimes  a  mel- 
ancholia precedes  the  circular  psychosis;  the  first  is  cured,  and 
after  a  year  or  even  after  several  years  the  circular  disease 
appears. 

In  regard  to  the  special  psychic  phenomena  in  the  melan- 
cholic and  maniacal  stage,  compare  mania  and  melancholia. 

It  is  important  to  state  here  that  both  the  expansive  delu- 
sions of  mania  and  the  depressive  ones  of  melancholia  in  the 
circular  psychoses  very  seldom  rise  to  the  same  degree  as  those 
in  typical  cases  of  mania  or  melancholia ;  yet  both  maniacal 
raving  and  anxious  and  katatonic  stupor  appear. 

Hallucinations  appear  in  sporadic  cases,  but  are  not  fre- 
quent. 

Sometimes  the  melancholic  delusions  are  mixed  with  the 
paranoic,  and  the  depression  seems  to  be  partly  brought  forth 


198  Special  Psychiatry. 


as  a  reaction  from  the  persecutions  to  which  the  patient  thinks 
he  is  exposed. 

It  may  be  mentioned  in  connection  with  the  physical  symp- 
toms that  sphygmograms  have  sho^vn  that  a  heightened  tension 
of  the  arteries  exists  in  the  depressive  stage,  with  diminished 
activity  of  the  heart,  while  in  the  maniacal  stage  there  is  a  rapid, 
steep  ascent,  very  sharp  crests,  and  more  or  less  well-defined 
dicrotism.  The  respiration  is  accelerated  in  the  maniacal  stage, 
while  it  is  diminished  in  the  melancholic.  During  the  patholog- 
ical psychic  condition  the  urine  shows  indican,  acetone,  diacetic 
acid,  which  constituents  disappear  in  the  interval.  Some- 
times the  excretion  of  these  substances  precedes  the  attack 
(Pilcz).     Menstruation  is  seldom  altered  in  circular  psychosis. 

Etiology. — Circular  psychosis  seldom  appears  after  the 
thirtieth  year,  but  generally  in  the  second  or  at  the  beginning 
of  the  third  decennium  of  life:  it  is  more  frequent  in  women 
than  in  men  and  shows  a  greater  percentage  among  those  hered- 
itarily tainted  than  do  the  otlier  functional  psychoses.  It  must 
be  regarded  as  an  exception  if,  with  a  circular  psychosis,  the 
appearance  of  some  mental  disease  cannot  be  shown  repeatedly 
in  that  family. 

The  duration  of  the  single  attacks  or  the  phases  of  the 
attack  is  singularly  varpng.  Sometimes  there  is  a  daily  type, 
sometimes  the  single  t^^Des  occupy  the  space  of  from  three  to  six 
months,  and  even  longer. 

Besidts: — 

1.  Eecovery  is  very  rare;  weakening  of  the  intensity'  of  the 
single  phases  is  oftener  observed. 

2.  Transition  into  dementia  is  an  exception.  There  are 
cases  of  circular  psychoses  continuing  in  the  full  strength  of 
their  powers  of  reproduction  and  ideation  to  the  most  advanced 
age. 

Diagnosis. — Circttlar  psychosis  may  be  mistaken  for: — 
1.  The  circular  form  of  paresis.     Here  the  physical  symp- 
toms, especially  the  presence  of  paralytic  attacks,  are  decisive. 

3.  Circular-epileptic  insanity  on  the  basis  of  epilepsy.  Here 
the  classic  epileptic  seizures  or  the  epileptic  equivalents  will 
assure  the  diagnosis. 


The  Functional  Psychoses:  Paranoia.  199 

3.  Melancholia  or  mania  in  corresponding  stages  (which 
see). 

The  prognosis  is  unfavorable  for  recovery,  yet  interruptions 
of  the  disease  for  many  years  may  appear. 

Treatment. — Against  the  reappearance  of  the  attacks  one 
may  use  bromide,  atropin,  ergotin  as  in  periodic  mania  (which 
see).  One  combats  the  single  phases,  the  maniacal  exaltation, 
and  the  melancholic  depression,  according  to  the  principles  un- 
derlying these  conditions. 


5.  Paranoia.^ 

While  the  primary  element  in  mania  is  the  acceleration  of 
the  efflux  of  the  ideas,  in  melancholia,  hyperesthesia  and  neu- 
ralgia of  the  feelings;  in  paranoia,  the  disturbance  of  the  laws 
of  association  appears  as  the  primary  element,  in  that  either  one 
of  these  laws  obtains  the  mastery  over  the  others,  or  the  connec- 
tion of  the  ideas  is  not  perfected  according  to  the  laws  of  normal 
association. 

(a)   Rudimentary  Paranoia  (Morselli),  Imperative  Concepts. 

Imperative  concepts  may  consist : — 

1.  In  an  idea  or  a  certain  series  of  ideas  coming  into  the 
foreground  of  the  consciousness  so  that  all  others  are  relegated 
to  the  background. 

Either  this  occurs  continually  or  appears  only  on  certain 
occasions.  There  are  patients  who  are  incited  to  the  most  diverse 
calculations,  as  multiplying,  dividing,  extracting  the  square  root 
of  the  numbers  seen  on  houses,  coaches,  railroad  cars,  automobiles 
(arithmomania).  Moreover,  certain  numbers  are  often  con- 
nected with  a  peculiar  signification  (the  number  13).  In 
others,  it  is  certain  words,  definite  images  of  the  memory,  which 
constantly  reproduce  themselves  and  from  which  the  patient 
cannot  free  himself.  Thus  there  are  persons  who  cannot  rid 
themselves  of  the  thought  that  others  are  behind  them.     One 


^  Ziehen.  Areliiv  fiir  Psychiatrie,  xxiv.  Cramer.  Zeitschrift  fiir 
Psychiatrie,  vol.  51.  Mendel  in  Eulenburg's  Realencyclopadie,  3.  Auflage 
Werner.     Die  Paranoia.     1891. 


200  Special  Psychiatry. 


of  111}-  patients  was  constrained  to  imagine,  whenever  a  person 
entered  tlie  room,  how  well  the  naked  feet  of  the  visitor  would 
look,  whether  they  were  clean  or  dirty.  A  young  lady  of  twent}'- 
one  years  could  not  escape  the  idea  that  she  would  have  a  child, 
because  a  man  had  dragged  her  away  in  her  sixth  year. 

2.  Imperative  concepts  may  arise  because  the  associations 
perfect  themselves  with  special  predilection  and  vigor  in  one 
or  another  of  the  laws  of  association.  While  similarity,  coexist- 
ence, and  succession  preferabh'  rule  the  procession  of  the  asso- 
ciations in  the  thoughts  of  normal  beings,  in  pithological  states 
associations  otherwise  evolved  may  obtrude  themselves. 

(rt)  Imperative  concepts  b}^  the  insistence  of  contrast ing 
associations.  "VThile  praying,  the  patient  curses  to  himself;  he 
pictures  the  sexual  parts  of  the  Virgin  ]\Iary  while  praying  to 
her;  while  at  the  theater  he  debates  whether  he  should  not  call 
"fire,"  or  snatch  the  rifle  of  the  sentinel  as  he  passes  by. 

Contrasting  thoughts  then  lead  him  to  extreme  sl-epticism. 
TMiether,  although  he  has  extinguished  the  light,  a  spark  may 
not  have  fallen  somewhere  now,  whether  the  door  has  been 
locked,  whether  he  has  not  written  "no"  instead  of  "yes,"  whether 
the  letter  has  not  fallen  beside  the  post-box,  whether  he  did 
not  steal  something  which  was  said  to  have  been  stolen,  whether 
he  has  not  been  guilty  of  lese  majeste,  whether  in  the  paper 
thrown  away  there  may  not  be  cause  for  accusation.  Sometimes 
the  fear  occurs  that  the  patient  may  betray  himself  by  blushing 
(erythrophobia),  and  he  very  often  actually  blushes.  Some- 
times, as  in  the  phobias,  there  is  connected  therewith  the  dread 
of  touching  objects,  not  from  a  hypoeliondric  fear  of  becom- 
ing infected,  but  from  fear  of  placing  poison  or  something  else 
injurious  thereon,  and  injuring  others  in  this  manner. 

(h)  Imperative  concepts  arise  while  the  associations  are 
perfected,  preferably  after  the  association  laws  of  cause  and 
effect  (metaphysical  mania).     One  can  distinguish  here:  — 

1.  The  metaphysicians:  Why  has  God  created  the  world? 
Why  does  immortality  exist? 

2.  The  realists :  Why  do  the  people  in  tlie  basement  have  no 
windo-n'  shutters?  Why  are  they  not  afraid  of  burglars?  Why 
do  men  have  two  legs,  and  not  four  ?  Why  are  leaves  green,  and 
not  blue?     If  I  should  think  of  stabbing  my  mother,  would  it 


The  Functional  Psychoses:  Paranoia.  201 


do  any  injury  if  I  only  think  it,  or  docs  it  not  injure  if  I  do 
not  do  it? 

This  pathological  condition  may  appear  externally  as  7no7-- 
hid  curiosity    (phrenolepsia  erotematica,  Meschede). 

In  all  these  states  there  is  full  consciousness  of  disease. 

Hallucinations  do  not  appear  with  these  imperative;  con- 
cepts. Disagreeable,  disgusting  feelings,  which  many  patients 
recognize  as  unendurable  anxiety,  pathological  mental  processes, 
caused  through  the  fear  that  they  will  lead  to  the  "loss  of  reason," 
regularly-  accompany  these  states. 

Sometimes  imperative  concepts  lead  to  actions  of  an  impul- 
sive nature;  but  these  last  consist  mostly  in  ejaculating  words 
which  correspond  to  the  surging  ideas  and  are  often  nonsensical 
(onomatomania),  sometimes  the  last  are  of  an  indecent  nature 
(coprolalia)  in  connection  vnth  spasmodic  tics  in  the  motor 
apparatus.  The  fear  of  such  things  often  cramps  their  inter- 
course with  other  persons;  the  patients  are  afraid  of  going  to 
church,  to  the  theater,  even  on  the  street.  The  complete  mastery 
of  the  patient  by  the  concepts  may  bring  him  to  the  condition, 
transitory  or  permanent,  of  not  being  able  to  perform  the  duties 
of  his  occupation;  in  severe  cases,  getting  up  and  dressing  him- 
self is  very  difficult ;  everything  consumes  a  great  deal  of  time. 

Etiology. — Eudimentary  paranoia  arises,  in  the  majority 
of  cases,  from  twenty  to  thirty  years  of  age,  but  sometimes  may 
appear  in  children.  The  hereditary  basis  is  the  most  important 
predisposing  factor. 

As  a  rule  it  affects  men  who  from  youth  up,  even  in  school, 
have  been  earnestly  endeavoring  to  make  their  lives  difficult. 

The  principal  cause  for  the  outbreak  of  the  disease  is  found 
in  many  eases  in  a  sudden  severe  shock  to  the  mind,  or  con- 
tinual grief,  sometimes  by  physical  and  mental  overexertion  with 
consequent  exhaustion  and  insomnia. 

The  appearance  is  sometimes  very  sudden,  but  mostly 
gradual. 

The  course.  In  cases  in  which  hereditary  taint  does  not 
exist,  and  when  it  arises  acutely  on  the  basis  of  exhaustion,  the 
pathological  symptoms  may  disappear  in  a  few  weeks.  The 
course,  as  a  rule,  is  chronic,  with  numerous  remissions  and  ex- 
acerbations, seldom  periodical. 


2^  Special  Psi/chiatrv. 


1.  Oompleie  TecDTerr,  as  remarked  aboTe.  or  TeeoTerr  Trith 
fenflfinej"  i®  leiapgfis. 

2-  Oonfrn-naxian  of  the  disease  -with  Temissioiis  and  es- 
aeeriaaiians. 

S.  TraTmrtnaii  iui©  t|r^ieal  paranoia,  Terr  rare. 

4.  Death  "bj  snidde,  Vbieh  the  patient  commits  from  fear 
of  iBsanirT  ot  lieeatise  ie  cannot  longer  endure  ids  angnish. 

I^ia.ffnom&. — -^  a  deosipe  spaptom  in  lihe  assumption  of 
imperatiTe  caneepts,  in^-glii  into  ih.€  dwsase  present  must  be 
>eDinsidered_  He  idio  is  aiaeeted  Isj  ihese  ideas  nmst  confess  that 
iiffT  ais  'Of  pathologieal  nature.  Tliere  are  naanr  transitions 
l>etween  the  impiilsTe  Tial^iis  Triich.  oecasionallT  appear  "with. 
■&£  ifiafthr,  and  Trliieh  iiave  amen  fregnently  from  fanltr  edn- 
Eaaimi  or  precept,  and  Ihe  impsraiive  eoneepis  of  mdimealarT 
parsnoia-  There  are  also  Tare  easffi  in  vlnch  a  transition  of 
:&£  ccmBBpiians  into  dehiaons  taks  place. 

The  primarUiy  appearing  imperatiTe  concepts  are  to  be  dis- 
tfm^'uTBhed  ' — 

1.  Jrom  the  secondary  ideas  arising  on  the  basis  of  a  central 
-DBirrreas  m:  a  psrchcsis  of  oppTessre  poorer,  "vrliiciL  are  STmptoms 
a±  ihE  earTfisponding  disease.  An  insistent  idea  of  the  imfaith- 
fnhieffi  of  one's  companion  in  mamage  mar  appear  on  the  basis 
■of  ltafst,eria:  iiTsteiie  jealons  insanitr,  Trliieh  sometrmes  is  dis- 
tangnKhed  idfli  ffimenlltj  from  exeessre  j^onsr;  someiimes 
id^is  in  Tegard  to  tie  3irffi5nTe  of  "Ehe  urine,  fiatnlenee,  Bexaal 
THiags  irlneh  crmtfrrmaTlx  oppr^  Irrstericals. 

-  n  3j»3£^Mm,  TBgnlarbr  Tennning,  impeDfint  ideas  may  form 
tne  Ema  of  ihe  epileplic  seizicre  or  the  egrnralent  of  the  same, 
and  sometimes,  also.   oeenpT  the  patient  dining  the  interralB. 

Im  tioE  eonneeiion  ther  wight  he  called  Tiystsric  or  epileptic 
impemin/Pi  conc€pi&. 

In  flie  meet  diverse  pgpeliosee,  e^^eciaJlj  among  fbe  melan- 
eholiaeB  and  paaancdaeE.  inastsit  delvMons  mar  appear  domi- 
TtRTifh-  in  the  f  orBgronnd. 

Th^se  impnlsire  delnsians  are  to  he^distm^rdshed  from  im- 
gjessiOve  eanBepdB  hx  a  ecEmpaiifion  of  fhe  different  genes^,  one 
■of  Trhieh  Tenjak  Irr  fhe  ananmeaa  an  indiTidnal  psrehicallT  dis- 
eased, the  other  a  peison  mentaUr  sound:  ihe  clinical  pietnre 


Tu€  Funciional  Pgychose?:  Paranoia.  203 

witli  other  grmptoms  of  mental  disease  miming  a  rerr  diverse 
course,  as  a  rule  tenninating  in  reooverr :  the  other  type  num  Ing 
a  chronic  course,  eren  thon^  the  intensitr  of  the  process  mar 
varr.  without  the  indiTidual  being  or  becoming  mentallT  dis- 
eased. 

2.  Ftoih  the  phobias  which  arise  on  the  basis  of  hrpo- 
chondria. 

3.  From  tL-?  rt^-'J  ..T'-y  oppressixe  ideas  {'hke  residuarr  hal- 
lucinations) viiicii  reiiiair.  behind  for  a  long  time  after  the 
termination  of  a  psrehosis. 

The  prognosis  tor  a  complete  permanent  recorery  in  para- 
noia rudimentaxia  is  not  faTorable  in  the  great  majoritT  of 
eases. 

The  treatment,  aboxe  all.  eon=isT3  in  agreeable  <iiTer=ions, 
espeeiallT  br  physical  labor,  bj  engaging  in  spens.  "nndenaking 
Jonmers  in  srmpathetie  company  (only  exceptionally  saiding  to 
institutions,  if  erery  other  arenue  is  closed  or  if  it  is  impossible 
to  keep  the  patient  at  home),  hydrotherapy  in  the  most  Tarious 
forms;  finally,  psychic  influence,  by  which  one  diould  endeaxor 
in  all  ways  to  assure  the  patient  that  he  will  not  become  insane. 
about  which  he  is  almost  always  in  the  great^^  anxiety 
with  a  xixid  oonsciousn^  of  disease.  For  remedies  aKenic  may 
be  used,  and  nitroglycerine  (in  drops  or  tablets  at  0. 00*35  to 
0.001,  sexeral  time  daily.  The  patient  diould  be  quieted,  in 
the  occasional  esaeerbations.  by  the  employment  of  bromide 
preparations,  phenacetin  or  pyramidon, 

{h)   T>-pical   Paranoia. 
1.  Acute  Simple  Paranoia. 

The  disease  begins  with  insomnia,  anorexia,  or  depr^sion. 

The  patient  beliexes  he  obserxes,  at  L : :  "  on  the  street,  that 

special  attention  is  being  directed  toward  r-:~  mi  connects 
extraneous  circumstances  with  this  (^delusi:-  :  serxation. 
pathological  self-interest,  Xeisser).  He  thinks  that  people 
wish  something  from  him  or  wish  to  mock  him.  joke  about  him. 
The  disease  generally  passes  by  in  sexeral  months,  with  gradual 
tranquilization  and  without  coming  to  further  s;f5tematie  devel- 
opment. 


204  Special  Psychiatry. 


Magnan  -uiiderstancls  by  delire  d'emblee  (fulminatiiig  deli- 
rium) "ft-here  there  is  strong  hereditarj'  taint,  persecution  and 
grandiose  ideas,  which  appear  suddenly  and  reach  their  cul- 
minating point  in  a  few  hours,  and  which  often  pass  over  into 
recovery  in  a  few  weeks.  With  this  a  transitory  state  of  con- 
fusion may  appear.  I  have  sometimes  seen  such  short  states 
of  ideas  of  jDersecution.  sometimes  lasting  only  several  days, 
especially  in  the  climacteric  and  in  connection  with  menstru- 
ation.    Eelapses  sometimes  occur. 

2.  Clironic  Simple  Paranoia  (Combined). 
The  disease  begins  so  gradually  that  generally  the  time  of 
its  beginning  cannot  be  fixed. 

1.  Initial  stage.  The  disease  is  so  insidious  that  it  is  not 
unmistakably  recognized  by  the  friends  and  relatives  of  the 
patient,  until  a  considerable  time  after  the  outbreak.  The 
patient  becomes  a  recluse  and  non-communicative.  On  the  other 
hand,  he  is  easily  excited,  disturbed,  and  even  violent.  Some- 
times his  bizarre  movements,  the  peculiar  intonation  of  single 
words  attract  attention.  "With  this,  his  physical  health  appears 
essentially  undisturbed;  however,  sleep  is  defective  and  the 
appetite  is  fickle.    The  patient,  however,  attends  to  his  business. 

2.  The  paranoic  stage.  The  patient  sometimes  shows  his 
delusion  very  suddenly,  whether  it  be  in  connection  with  some 
peculiarly  exciting  occurrence  or  a  slight  fever:  "1  have  long 
remarked  that  people  have  noticed  me,  that  they  are  attentive 
to  me,  that  they  point  to  me  everywhere.  There  must  be  a 
conspiracy  against  me,  perhaps  I  have  a  double.  I  never  feel  safe 
on  the  street  for  a  moment;  allusions  to  me  are  made  even  in 
the  newspapers."  But  he  not  only  thinks  that  the  present  refers 
to  liim  in  all  its  occurrences  (delusion  of  relation),  but  he  thinks 
the  same  of  the  past :  "People  have  persecuted  me  and  still  per- 
secute; Social  Democrats,  Free  Masons,  the  police  watch  me 
constantly."  If  asked  what  end  the  persecution  serves,  he 
answers :  "I  do  not  know  what  it  signifies.  Does  any  one  wish 
to  test  me,  does  any  one  wish  to  get  something  from  me  ?  There 
must  be  some  secret  in  it.  At  all  events.  I  appear  to  be  the 
object  of  special  attention."  In  the  further  course,  the  secret 
is  discovered  by  the  patient :     "People  have  found  out  my  im- 


The  FtniclioiKtl  Psychoses:  Pdranoia.  205 

portance,  but  wish  to  hinder  me  from  taking  the  rank  due  me 
in  science,  in  art;  for  this  reason  they  wish  to  destroy  me,  body 
and  soul."  "They  know  that  I  am  of  royal  lineage,  that  I  am 
called  to  take  the  throne,  to  found  a  new  religion,  and  they  con- 
fine me  in  an  institution  to  render  me  innocuous.  Thus 
the  ideas  of  persecution  and  of  grandeur  gradually  become 
systematized  in  logical  sequence.  In  a  series  of  cases,  instead 
of  reaching  the  above-described  megalomania,  it  only  comes  to 
slight  over-appreciation  of  himself,  which  is  first  perceived  on 
careful  examination.  But  sometimes  every  hint  of  a  grandiose 
idea  is  lacking ;  on  the  other  hand,  there  is  a  feeling  of  a  certain 
mental  inferiority:  "They  wish  to  get  rid  of  me,  since  I  am 
too  weak  to  struggle  for  existence."  In  other  cases  the  ideas 
of  persecution  seem  to  be  lacking,  and  only  grandiose  ideas  seem 
to  exist;  yet  an  exact  anamnesia  will  prove  that  the  first  have 
existed  earlier. 

Where  the  trend  of  the  delusion  has  been  in  a  single  direc- 
tion, some  have  spoken  of  a  fixed  idea  and  thought  that  the 
patient  was  mentally  diseased  only  on  that  one  point.  The  in- 
correctness of  this  assumption  has  already  been  shown. 

Many  of  the  insane  "inventors,"  "reformers,"  and  a  con- 
siderable number  of  the  so-called  querulants  are  recruited  from 
the  paranoiacs. 

3.  The  stage  of  dementia.  With  the  diminution  of  the 
energy  a  state  of  mental  weakness  gradually  enters,  frequently 
only  after  decades.  The  prophets,  emperors,  and  kings  then 
lead  a  quiet  existence  in  the  institutions  and  may  be  suitably 
occupied  there.  In  a  series  of  cases  the  delusions  systematized 
earlier  in  the  course  of  the  disease  are  repeated  nonsensically 
in  variegated  confusion:  "I  am  the  daughter  of  the  Empress 
Frederick,  heathenish  Jesuit,  Katy  of  Heilbronn,  influenced 
spiritistico-magnetically,  persecuted  by  Free  Masons." 

3.  Acute   Hallucinatory  Paranoia. 

The  clinical  type  and  the  course  are  essentially  the  same  as 
those  of  acute  simple  paranoia,  and  distinguished  from  this  only 
by  the  presence  of  hallucinations. 

The  disease  is  wont  to  last  from  a  few  weeks  to  several 
months,  is  distinguished  from  hallucinatory  delirium  essentially 


206  Special  Psychiatry. 


by  tlie  circumspection  existing  in  paranoia^  the  lack  of  confusion, 
and  the  systematization  of  the  hallucinations  and  delusions.  The 
disease  sometimes  appears  in  connection  with  dysmenorrheic 
conditions,  oftener  in  the  climacteric.  "Where  it  appears  on 
the  basis  of  an  intoxication,  especially  alcohol  intoxication,  it  is 
to  be  assigned  to  the  intoxication  psychoses,  and  not  to  the 
functional  psychoses. 

4.  Chronic  Hallucinatory  Paranoia. 

1.  Initial  stage.  The  disease  regularly  begins  with  spor- 
adic, entirely  abrupt  hallucinations  of  audition,  foreign  to  the 
entire  content  of  the  thought  of  the  patient:  "Rascal,"  "boor," 
"Old  August,"  "you  must  marry."  The  patient  is  at  first  in- 
clined to  believe  that  he  is  being  deceived,  seeks  after  those  who 
have  called,  and  graduall}'-,  from  the  constant  return  of  the 
hallucinations,  becomes  convinced,  instead  of  doubting ;  he  knows 
that  he  is  the  object  of  persecution. 

2.  Paranoic  stage.  In  the  same  manner  as  in  simple 
chronic  paranoia,  the  delusions  of  persecution  develop,  and  later 
those  of  grandeur.  Meanwhile  there  are  often  states  of  excite- 
ment caused  by  the  heightening  of  massive  hallucinations;  these 
states  may  show  transitorily  the  type  of  hallucinatory  delirium 
and  even  reach  raving  excitement. 

3.  The  stage  of  dementia  is  accustomed  in  this  type  to 
appear  earlier  than  in  simple  paranoia.  But  here  quite  often  a 
decade  passes  before  there  is  weakening  of  the  intellect. 

Varieties. 

1.  Hypochondric  paranoia.  There  is  a  form  of  chronic 
paranoia  in  which  the  chief  symptom  consists  of  hallucinations 
of  the  coenesthetic  sense,  which  is  generally  the  forerunner  of 
the  disease.  At  its  height  the  patient  says  that  his  body 
is  annihilated,  that  they  have  destroyed  all  his  organs  sin- 
gly, that  he  is  a  whole  hospital,  his  persecutors  have  done  this 
by  magnetism,  by  injurious  vapors,  by  poison  in  his  food.  Those 
persecutors  are  Free  Masons,  "lUuminati,"  the  first  dignitaries 
of  the  state,  they  intend  to  prevent  him  from  attaining  his 
purpose. 

2.  Primitive  paranoia      (Sander).     The    disease    develops 


The  Functional  Psychoses:  Paranoia.  207 

even  in  cliiklhood,  with  a  degenerate  family  history  as  a  founda- 
tion, with  peculiarities,  reservations,  cither  in  a  quiet,  diffident, 
dreamy,  or  malicious,  irascible  nature  with  hypochondric 
ideas,  sometimes  with  nocturnal  fears,  convulsions,  with  consid- 
erable disturbance  of  the  bodily  development  and  excessive 
onanism.  The  patients  perceive,  even  in  school,  persecutions  in 
the  conduct  of  their  schoolfellows.  With  the  entrance  of  the 
years  of  puberty  there  is  the  development  of  a  complete  psychosis, 
sometimes  with  katatonic  stupor,  with  frequent  change  of  the 
4;ypes,  now  maniacal  exaltation,  then  melancholic  or  hypochon- 
dric depression.  With  these,  delusions  of  persecutions  exist, 
sometimes  ideas  of  grandeur.  Stories  and  romances  often  sup- 
ply these  delusions  with  their  content. 

Many  of  these  patients  are  distinguished  by  their  inclina- 
tion to  fabrication  {paranoia  confab ulans) .  This  is  a  form  of 
paranoia  which  leads  to  dementia  prcecox. 

3.  Paranoid  melancholia,  a  combination  of  melancholic  with 
paranoic  delusions :  "People  make  hints,  reproach  me,  tease  me, 
turn  away  from  me,  threaten  me  with  severe  punishment.'^ 
With  this,  they  explain  that  the  treatment  which  they  receive, 
the  threatened  punishment,  does  not  correspond  with  the  slight 
fault  which  they  may  have  committed,  when  they  did  not  per- 
form their  duty  satisfactorily,  when  they  did  not  remain  at 
home,  when  they  went  walking  with  a  man,  and  the  like. 

4.  Paranoid  dementia.  Kraepelin  has  comprehended  un- 
der this  name  those  cases  in  which  the  paranoic  ideas  are  very 
absurd  and  fantastic  from  the  beginning,  and  in  which  the 
patients,  especially  children,  but  also  the  aged,  quickly  reach 
a  childish  confusion. 

5.  Some  of  these  cases  of  paranoia  do  not  develop  in  the 
second  stage  in  the  manner  described,  but  a  transitory  or  per- 
manent katatonic  state  appears,  as  has  been  already  described 
{hatatonic  paranoia). 

6.  In  rare  cases  the  paranoia  runs  a  periodical  course  {pe-^ 
riodical  paranoia). 

Special  Symptomatology. 

1.  Hallucinations.  While  in  simple  paranoia  illusions  or 
hallucinations  do  not,  or,  sometimes,  only  transitorily,  appear. 


208  Special  Psychiatry. 


hallucmations  appear  and  characterize  the  begiiming  and  course 
of  hallucinatory  paranoia.  Above  all,  they  are  hallucinations 
of  the  auditory  sense  which  frequently  appear  first  in  single 
words  or  sentences.  More  often  there  is  audibility  of  thought. 
The  auditory  hallucinations  are  rarely  unilateral  or  doubled. 
Sometimes  the  voices  are  in  the  lar^Tix,  in  the  breast,  in  the 
abdomen.  In  sporadic  cases  the  patient,  on  the  basis  of  his  hal- 
lucinations, reaches  the  conclusion  that  there  is  another  beside 
the  Ego  (double  personality).  A  triplication  also  appears: 
"Besides  the  Ego,  God  and  the  devil  are  in  my  head  and  combat 
each  other."  Hallucinations  of  smell  and  taste  are  frequently 
connected  with  ideas  of  poisoning:  visual  hallucinations  are 
relatively  rarer.  The  hallucinations  of  the  coenesthetic  sense 
have  already  been  mentioned  under  hypochondric  paranoia. 
As  a  result,  a  state  of  stupor  may  arise,  the  patient  feels  that 
some  one  is  holding  his  tongue,  his  hands,  or  other  organs  (stu- 
porous paranoia,  Ziehen). 

2.  Thought.  Memory  and  intelligence  may  remain  unim- 
paired in  paranoia  for  many  years,  even  for  decades.  A  patient 
with  hallucinatory  paranoia,  while  in  my  hospital,  wrote  a  work 
on  modern  Greek  literature  which  received  favorable  criticism. 

The  delusions  which  appear  in  paranoia  are,  first,  the  de- 
lusion of  persecution,  which  develops  from  the  delusions  of  atten- 
tion and  of  relation.  But  the  patients  do  not  think,  as  the  per- 
secuted melancholiac  does,  that  the  persecution  has  a  cause 
founded  in  their  life  and  actions,  but  they  are  convinced  that 
the  persecution  is  in  the  interest  of  others.  In  this  delusion  of 
persecution  the  patients  sometimes  consider  themselves  the 
center  of  all  events  which  take  place  and  which  are  always 
directed  against  them  (delirium  conrergens).  The  persecutors 
are  usually  at  first  unknown  ("They  persecute  me,"  "A  man 
has  ruined  me  by  sharp  glances,"  "I  have  been  photographed 
while  bathing,  the  photographs  have  been  distributed  among 
the  people")  ;  later,  special  persons  are  named,  oftener  groups 
of  persons:  "The  lodge,"  "the  brothers  of  the  black  hand,"  and 
like  utterances.  Connected  with  the  ideas  of  persecution  are 
metabolic  or  palingnostic  delusions,  in  which  the  patient  trans- 
forms his  ideas  of  those  around  him  to  correspond  to  his  delu- 
sion.    The  attendants  are  disguised  detectives  or  officials  who 


The  Functional  Psychoses:  Paranoia.  209 

serve  him.     The  identifying  form  of  the  deception  of  the  mem- 
ory is  also  observed. 

Where  the  delusions  relate  especially  to  erotic  matters,  the 
patient  suffers  from  ei-otic  paranoia,  for  which  Don  Quixote 
gives  us  the  classical  type.  Such  patients  see  in  the  ciphers  in 
the  journals  allusions  to  themselves.  In  other  cases  the  paranoia 
appears  as  the  delusion  of  jealousy. 

In  religious  paranoia  the  patient  finds  hints  for  his  true 
avocation  in  the  Bible  or  in  sermons;  persecuted  paranoiacs 
assume  that  the  devil  has  taken  possession  of  them,  that  they  are 
bewitched  (demonomania). 

In  a  number  of  cases  the  persecuted  and  injured  paranoiacs 
become  persecutors.  To  these  belong,  also,  some  of  those  who 
suffer  from  querulant  paranoia;^  while  they  believe  that  they 
have  suffered  in  their  rights,  they  attack,  in  complaints  and  writ- 
ings, those  who  they  think  have  caused  this,  injure  their  sup- 
posed interests  as  much  as  possible,  and,  since  they  pass  all 
bounds  with  their  complaints,  are  quite  often  subjected 
to  new  litigation  for  offending  the  judges,  for  accusing  the 
witnesses  of  perjury,  for  lese  majeste.  This  form  of  paranoia 
first  breaks  out  late — in  the  fourth  to  fifth  decade  of  life.  The 
accidental  cause  of  the  outbreak  of  the  disease  is  generally  un- 
fortunate litigation.  The  intelligence,  the  pettifogging  logic, 
and  sometimes  an  excellent  memory,  which  holds  always  at 
tongue's  end  the  code  of  the  civil  and  criminal  procedures,  often 
deceive  the  judge  as  to  the  morbidness  of  the  condition  and 
sometimes  the  physicians  as  well. 

A  state  of  mental  weakness  usually  appears  very  late. 

3.  Sometimes  the  speech  of  paranoiacs  shows  nothing  note- 
worthy; sometimes  they  utter  in  sentences  peculiar  nonsensical 
words,  generally  consonant  with  their  hallucinations,  in  a  dis- 
course which  is  otherwise  intelligible :  "They  accuse  me  of  char- 
latanism at  the  drug  store,"  "rabid  speech."  Sometimes 
paranoiacs  do  not  speak  at  all,  either  from  the  influence  of 
hallucinations,  of  stupor,  or,  e.g.,  in  order  not  to  betray  their 
presence  by  speech. 

Sometimes  cabalistic  signs,  underlining  of  single  words 
which  have  a  relation  to  delusions,  are  found  in  manuscript. 

^Hitzig.    Ueber  den  Quarulantenwahnsinn.    Leipzig,  1895. 

14 


210  Special  Psychiatry. 


4.  The  actions  of  paranoiacs  show,  in  a  series  of  cases, 
nothing  striking,  so  that  the}'  are  able  to  carry  on  their  business 
in  a  regular  way  and  only  betray  their  mental  disease  if  one 
speaks  of  the  dominant  series  of  delusions  which  occupies  them. 

Sitophobia  in  paranoiacs  often  appears  in  consequence  of 
ideas  of  poisoning,  and  is  also  observed  in  the  stuporous  state 
already  mentioned.  Suicide  is  rare  in  paranoiacs  as  compared 
with  melancholiacs. 

For  the  rest,  paranoiacs  belong  to  the  most  dangerous 
maniacs.  They  show  considerable  intelligence  in  their  delu- 
sions, which  aids  them  in  the  choice  of  means  to  take  revenge 
on  their  persecutors,  and  they  often  accomplish  their  object. 
Paranoiacs  play  a  considerable  part  in  history,  especially  in 
murderous  attempts  upon  persons  high  in  position. 

5.  Physical  symptoms.  Paranoia  offers  no  peculiarities 
except  the  common  physical  symptoms  of  mental  disease.  In 
hypochondrie  paranoia  a  speeiall}'  accurate  examination  of 
the  internal  organs  is  necessary,  since  hypochondrie  delusions 
are  not  so  very  seldom  connected  with  special  physical  changes. 

Etiology. — x\mong  the  functional  psychoses  paranoia  takes 
the  third  place  after  delirium  hallucinatorium  and  melancholia 
in  point  of  frequency.  Chronic  simple  paranoia  is  the  most  com- 
mon, acute  simple  paranoia  is  the  most  rare.  For  the  rest, 
paranoia  is  not  distinguished  etiologically  from  the  other  mental 
diseases. 

The  outhrcah  of  paranoia  is  usually  gradual.  The  course 
may  be  (1)  acute  or  subacute,  (2)  progressive,  as  it  is  described 
above,  and  (3)  remittent,  in  that  sometimes  there  is  a  fading 
out  of  the  delusions  and  with  it  more  or  less  tranquillity.  The 
duration  in  the  acute  type  is  from  a  few  weeks  to  some  months; 
in  the  chronic  type,  a  lifetime. 

Diagnosis. — The  diagnosis  of  paranoia  is  not  made  by  the 
fact  that  paranoic  delusions  are  present,  but  it  must  be  shown 
that  these  delusions  are  the  primary  and  essential  ones  of  the 
disease.     Paranoia  may  be  confounded  with 

1.  Melancholia,  from  the  ideas  of  persecution  present.  We 
have  discussed  previously  how  the  paranoiac  and  the  melan- 
choliac  behave  in  the  presence  of  persecutions. 

2.  Hypochondrie    melancholia,     from    the     hypochondrie 


The  Functional  Psychoses:  Acute  Dementia.  211 

delusions.  Even  here,  since  the  phenomena  may  have  the  same 
content  as  the  hypoehondric  delusions,  it  is  ol'  im])()rtance 
in  the  differential  diagnosis  that  the  nielancholiac  regards  the 
pathological  change  as  a  punishment  for  his  sinful  life,  but  tlie 
paranoiac  as  a  consequence  of  the  misdeeds  of  his  persecutors. 

3.  The  differential  diagnosis  with  delirium  hallucinatorium, 
which  is  of  importance  with  special  reference  to  acute  hallu- 
cinatory paranoia  and  transitory  states  of  confusion  in  chronic 
hallucinatory  paranoia,  has  already  been  mentioned. 

4.  Paranoia  is  distinguished  from  the  paranoic  delusions 
in  organic  brain  diseases  by  the  absence  of  all  symptoms  of  an 
organic  lesion,  from  those  which  are  called  forth  by  intoxica- 
tions, by  the  lack  of  symptoms  denoting  intoxication,  and  by 
the  anamnesia. 

5.  Finally,  especial  regard  to  dissimulation  should  be  ob- 
served in  the  diagnosis  of  paranoia.  Sometimes  great  psychi- 
atrical experience  and  long  observation  of  paranoiacs  are  neces- 
sary to  be  sure  of  the  disease,  especially  if  the  patient  thinks  that 
he  is  under  observation. 

Treatment. — In  the  acute  forms  of  paranoia  commitment 
to  an  institution  seems  necessary  for  a  speedy  cure.  As  for  the 
chronic  forms,  treatment  in  an  institution  is  desirable  on  account 
of  the  homicidal  tendencies  of  the  patient  in  hallucinatory  para- 
noia, so  long  as  weakening  of  the  intellect  or  of  the  energy  has 
not  appeared.  The  same  is  also  true  of  chronic  simple  paranoia 
as  soon  as  the  behavior  of  the  patient  shows  that,  from  being 
persecuted,  he  may  become  a  persecutor  or  has  already  become 
one,  or  that  his  grandiose  ideas  may  lead  to  dangerous  actions. 
For  the  rest,  the  treatment  of  paranoic  patients  should  be 
essentially  symptomatic. 

6.  Acute  Dementia.  1 

Acide  dementia  is  a  functional  psychosis,  which  is  charac' 
terized  by  the  primary  appearance  of  a  more  or  less  complete 
paralysis  of  the  7nental  functions. 

After  a  short  preliminary  stage  tlie  patient  presents  the 


^  Binswanger.     Charitg-Annalen,  vol.  vi.     Schiile.     Zeitschrift  fiir 
Psychiatrie,  vol.  xxxviii. 


212  Special  Psychiatry. 


image  of  complete  disorientation.  He  knows  neither  his  age 
nor  dwelling,  scarcely  his  name.  Sometimes  he  does  not  answer 
at  all,  and  scarcely  shows  any  mental  acti%dty.  With  this,  his 
gaze  is  directed  to  a  distance,  his  mouth  is  half  opened,  the 
saliva  trickles  therefrom,  the  lines  of  his  countenance  are  lax 
and  betray  no  expression  (hypotonic  stupor).  In  the  further 
course  of  this  state  the  patient  must  be  fed,  he  passes  urine  and 
feces  involuntarily.  Sometimes  a  greater  or  less  degree  of 
restlessness  is  observed.  The  pulse  is  generally  retarded,  the 
temperature  subnormal.  The  recovery  from  the  disease,  as  a 
rule,  is  reached  gradually;  in  time  the  patient  gains  his  former 
mental  power.  His  memory  during  the  course  of  the  disease, 
and  sometimes  also  for  some  days  before  it,  either  fails  com- 
pletely or  it  is  imperfect. 

Etiology.  This  disease  is  the  rarest  of  the  functional  psy- 
choses. It  attacks  preferably  young  persons  of  from  twenty  to 
thirt}''  5-ears  of  age,  more  frequently  males.  The  immediate 
cause  of  the  oiitirealc  is  sometimes  psychical  traumata,  anxiety, 
fright  (railway  brain).  It  is  sometimes  observed  after  immod- 
erate physical  or  mental  exertion,  after  unsuccessful  attempts  at 
suicide,  seldom  after  acute  affections.  The  duration  of  the  dis- 
ease extends  from  a  few  days  to  several  months.  The  results 
are: — 

1.  Eecovery  in  about  80  per  cent,  of  the  cases.  2.  Transi- 
tion into  terminal  dementia.  3.  Death  through  intercurrent 
diseases.     Accordingly,  the  prognosis  may  be  called  favorable. 

In  the  differential  diagnosis  one  should  consider: 

1.  Delirium  hallucinatorium  (which  see) . 

2.  Anxious  stupor  (delusional  stupor,  INTewington).  In  this 
ease  the  anamnesia  decides;  it  allows  the  melancholia,  which  is 
present  a  long  time  before  the  stupor,  to  be  recognized ;  further, 
the  expression  of  the  countenance,  which  is  very  melancholio- 
anxious  in  anxious  stupor,  is  blank  and  idiotic  in  acute  de- 
mentia. The  musculature  of  the  body  is  rigid  in  the  former, 
but  lax  in  the  latter.  With  the  former  there  is  sitophobia,  which 
can  be  overcome  only  by  force ;  in  the  latter,  nourishment  is 
taken  with  the  help  of  others  without  resistance. 

3.  Anamnesia  and  course  decide  in  the  twilight  conditions 
of  the  pre-  and  post-epileptic  states. 


The  Epileptic  Psychoses.  213 


4.  In  regard  to  the  aphasic  condilions,  the  expression  of  the 
face  may  come  from  a  man  who  has  become  acutely  idiotic  and 
be  connected  with  aphasia  apraxia;  thus  the  clinical  type  may 
be  allied  with  that  of  idiocy.  The  apoplectic  origin  of  the  affec- 
tion, the  hemiplegia  usually  present  on  the  right  side,  and  the 
more  exact  confirmation  of  the  aphasic  condition  will  confirm  tlie 

diagnosis. 

Treatment.  The  therapy  of  acute  dementia  must  be  tonic, 
with  abundant  nitrogenous  diet,  beer  and  wine.  The  quinine 
preparations  and  iron  are  to  be  recommended. 

Where  the  conditions  of  the  home  assure  constant  watching, 
the  patient  may  be  treated  at  home.  An  institution  will  be 
necessary  for  the  majority  of  the  poorer  and  middle  classes.  Eest 
in  bed  is  beneficial  in  all  cases. 

The  Pathological   Anatomy  of  the  Functional   Psychoses. 

A  pathological  anatomy  of  the  functional  psychoses  does  not 
at  present  exist.  However  little  it  may  be  doubted  that  there 
are  anatomical  changes  in  the  brain,  it  has  not  been  possible, 
so  far,  to  discover  characteristic  alterations.  The  occasional  find- 
ings are  partly  accidental,  and  their  ultimate  pathological  nature 
has  not  been  definitely  proved.  In  the  last  respect  we  still  es- 
pecially lack  a  confirmation  of  those  changes  in  the  ganglion 
cells  of  the  cortex  which  appear  even  in  the  domain  of  health. 
In  reference  to  terminal  dementia  after  functional  psychoses, 
see  "D.     The  Pathological  Anatomy  of  Mental  Diseases." 

III.  THE  PSYCHOSES  ARISING  FROM   CENTRAL 
NEUROSES. 

1.  The  Epileptic  Psychoses.^ 

Mental  disturbances  may  appear  in  epileptics: 

(a)  As  a  pre-epileptic  psychosis   (immediately  before  the 

seizure.) 

(b)  As  a  post-epileptic  psychosis   (immediately  after  the 

seizure) . 


^Pick  Zeitschvift  ftir  Heilkunde,  vol.  x.  Wildermuth.  Wuert- 
temberg.  Correspoudenzblatt,  1890.  Sommer.  Arcliiv  fiir  Psycluatne, 
vol.  xi. 


214  Special  Psychiatry. 


(c)   As  equivalent  of'  the  epileptic  seizure,  psychical  epi- 

leps}',  epileptoid  seizures,  twilight  couclitions  (epilepsia  larvata.)^ 

While  the  types  mentioned  run  an  acute  or  subacute  course, 

(cl)   A  chronic  mental  disease  may  develop  on  the  basis 

of  the  epilepsy. 

(a)  Pre=epileptic   Insanity. 

Preceding  an  ej)ileptic  seizure  minutas,  hours,  or  days,  a 
twilight  state  may  appear  in  which  complicated  actions  may  be 
completed  with  clouding  of  the  consciousness  and  exclusion  of 
the  self-consciousness.  These  have  an  automatic  character.  If 
clouding  of  the  consciousness  is  connected  with  hallucinations, 
the  condition  is  referable  to  dream  states  (see  twilight  states). 

Less  often  the  pre-epileptic  insanity  appears  as  a  state  of 
depression  with  melancholic  or  hypochondric  delusions. 
^Yhen  jmassive  hallucinations  appear,  these  may  rise  to  raving. 
The  epileptic  seizure  usually  ends  the  mental  disturbance,  yet 
sometimes  it  continues  as  a  post-epileptic  psychosis. 

(b)  Post=epiIeptic  Insanity, 

which  is  far  more  frequent  than  the  pre-epileptic,  may  appear 
as  a  twilight  or  dream  state.  With  this  appear  hallucinations 
of  sight,  often  visions  of  red  (Siemerling),  also  hallucinations 
of  smell  (odor  of  sulphur),  less  often  hallucinations  of  hearing. 

Less  frequently  post-epileptic  insanity  appears  as  maniacal 
exaltation,  increasing  to  raving,  or  as  melancholic  depression; 
in  the  last  case  generally  with  religious  ideas  (delusion  of  trans- 
gression) . 

The  paranoic  symptom-complex,  which  post-epileptic  in- 
sanit}''  sometimes  offers,  expresses  itself  especially  in  ideas  of 
persecution;  it  is,  also,  quite  often  connected  with  grandiose 
ideas.  With  these  appear  formidable  hallucinations  in  the  gen- 
eral and  coenesthetic  senses ;  a  stuporous  condition,  with  katatonic 
rigidity  of  the  muscles,  may  also  develop.  The  post-epileptic 
psychosis  seldom  shows  the  symptoms  of  acute  dementia. 

The  duration  of  the  post-epileptic  psychosis  may  be  from  a 


'These  expressions  are  often  used  promiscuously.  It  is  better  to 
call  those  of  sliort  duration,  running  like  a  sliort  epileptic  seizure,  epilep- 
toid, and  the  protracted  ones,  twilight  states. 


The  Epileptic  Psychoses.  215 

few  hours  to  several  months.  On  its  return  there  is  generally 
a  very  striking  resemblance  to  the  preceding  attack  in  regard  to 
hallucinations  and  delusions. 

During  the  period  of  the  psychosis  all  recollection  is  often 
wanting;  in  other  cases  this  is  summarily  present. 

(c)   Epileptic   Equivalents. 

The  epileptic  equivalent  may  run  from  a  state  of  uncon- 
sciousness, lasting  a  second  to  a  minute,  the  appearance  of  a 
swiftly  passing  imperative  concept,  to  the  development  of  a 
psychosis  lasting  from  weeks  to  months  (epileptic  equivalent, 
running  acutely  or  subacutely).  The  clinical  t3^pe  may  be  en- 
tirely similar  to  the  post-epileptic  psychoses  mentioned  in  the 
last  cases.  Sometimes,  also,  periodical  attacks  of  profound  sleep 
may  appear  as  equivalents  (epileptic  narcolepsia). 

Special  symptomatology  of  the  acute  or  subacute  epileptic 
psychoses. 

1.  The  hallucinations  affect  preferably  the  audition.  In 
two-thirds  of  all  the  cases  there  are  isolated  auditory  hallucina- 
tions ;  in  about  half,  visual  hallucinations ;  in  about  40  per  cent., 
hallucinations  of  both  senses.  Hallucinations  of  the  coenesthetic 
sense  are  frequent. 

The  hallucinations  are  mostly  of  a  terrifying  nature,  partly 
of  a  horrible  kind,  yet  they  are  often  pleasing,  phenomena  of 
God,  angels,  and  Heaven. 

2.  The  delusions  may  have  the  most  diverse  contents;  re- 
ligious delusions  are  frequent,  also  such  as  have  erotic  or  sexual 
content. 

3.  Self -consciousness  is  considerably  disturbed  in  all  epi- 
leptic psychoses,  or  transitorily  suspended  for  a  greater  or  less 
time. 

4.  The  actions  in  epileptic  psychoses  have  usually  some- 
thing sudden  and  violent,  and  the  patients  on  this  account  be- 
come peculiarly  dangerous. 

5.  Amnesia,  which  was  formerly  regarded  as  a  characteristic 
symptom  both  for  the  epileptic  seizure  and  the  acute  epileptic 
psychosis,  is  not  complete  in  many  cases ;  single  circumstances 
may  be  produced,  not  others  [island-formed  recollection^ 
Moeli) . 


216  Special  Psychiatry. 


6.  With  regard  to  the  physical  condition,  the  dilated  pupils, 
which  react  slowly  or  not  at  all  to  light,  are  to  be  mentioned, 
also  blunting  of  the  sensibility  and  exaggeration  of  the  tendon 
reflexes.  The  number  of  respirations  is  diminished,  while  the 
pulse  is  accelerated  and  the  temperature  is  generally  subnormal. 

Etiology.  Why  epileptic  psychoses  frequently  appear  in 
many  epileptics,  never  in  others,  is  not  known.  The  misuse  of 
alcohol,  psychic  and  somatic  traumata  may  favor  the  appearance 
of  psychoses;  puberty  may  act  in  the  same  way.  Pregnancy 
and  parturition  may  often  call  forth  epileptic  psychoses  in 
epileptic  women.  I  have  seen  epileptic  psychoses  break  out 
repeatedly  after  the  epileptic  seizure  had  been  suppressed  for  a 
long  time  by  large  doses  of  bromide;  in  others,  where  the  bro- 
mide, which  had  averted  the  seizure,  was  suddenly  discontinued. 
A  series  of  epileptic  seizures,  sometimes  a  status  epilepticus,  ends 
occasionally  with  a  psychosis. 

Diagnosis.  The  diagnosis  of  the  epileptic  psychosis  is  based 
on  the  anamnesia,  the  knowledge  of  epileptic  seizures  or  past  epi- 
leptoid  conditions.  Coincidentally,  scars  on  the  tongue,  on  the 
face,  especially  on  the  forehead  and  nose,  are  to  be  regarded 
as  signs  of  preceding  attacks.  If  there  is  no  anamnesia  to  con- 
firm the  diagnosis,  the  epileptic  nature  of  the  disease  is  made 
very  probable : 

1.  By  the  sudden  and  unexpected  appearance  of  the  mental 
disease. 

2.  By  the  obvious  obscurity  of  the  consciousness  (cloudi- 
ness, Moeli). 

3.  By  twitching  in  single  extremities. 

■4.  By  a  rapid  transition  with  total  or  partial  amnesia. 
In  the  differential  diagnosis  are  to  be  considered : 

1.  The  acute  alcoholic  psychosis.  There  is  often  a  com- 
bination of  epilepsy  and  alcoholism.  In  regard  to  the  alcohol- 
ism, the  anamnesia  and  presence  of  the  physical  changes  pro- 
duced by  alcohol  are  of  importance. 

2.  Psychoses  which  have  been  called  forth  by  organic  brain 
disease  (focal  disease,  paresis),  and  which  generate  epileptic 
seizures  as  a  symptom.  Here  the  examination  of  the  peripheral 
nervous  system  gives  the  necessary  evidence. 

Treatment.     Epileptic  psychoses  demand,  as  already  stated, 


The  Epileptic  Psychoses.  21 T 


most  careful  watcliinti";  and  if  they  do  not  terminate  in  a  few 
hours, as  they  often  do,  commitment  to  an  institution  is  necessary. 
The  treatment  should  be  directed  toward  relieving  the  epilepsy, 
and  large  doses  of  bromide,  digitalis,  and  atropin  may  be  used. 
To  obtain  calm  in  the  exalted  states,  chloral  hydrate  is  recom- 
mended, best  in  clysters  in  doses  of  two  to  three  grams.  • 

i 

(d)  Chronic  Epileptic  Psychoses. 

Where  epileptic  seizures  return  frequently,  weekly  or  several 
times  weekly,  and  even  where  they  appear  less  frequently  and 
continue  for  several  years,  a  pathological  mental  condition  gen- 
erally develops  whose  essential  characteristics  are  the  fol- 
lowing : 

1.  Eetardation  of  the  associations,  with  lack  of  judgment, 
want  of  endurance;  with  these,  laziness  at  school,  finding  the 
tasks  of  life  difficult;  further,  stunting  of  moral  perceptions 
which  previously  existed  (ethical  defects). 

2.  Loss  of  memory,  especially  in  regard  to  very  early  and 
recent  events. 

3.  Exaggerated  irritability,  with  diminished  power  of  re- 
sistance, quick  temper,  violent  actions.  The  restlessness  and  in- 
stability sometimes  lead  to  a  desire  for  wandering  (poriomania, 
Schultze) . 

4.  Facile  and  unmotived  change  of  the  disposition. 

5.  Hypochondric  moods,  the  patient's  complete  absorp- 
tion in  his  own  interests  and  a  corresponding  disdain  for  others. 
This  egotism  often  makes  the  epileptic  a  "family  panegyrist." 

Only  25  per  cent,  of  epileptics  may  be  regarded  as  mentally 
normal. 

The  mental  diseases  which  arise  on  the  basis  of  epilepsy 
appear  most  frequently  under  the  following  types: 

1.  Mental  weakness  up  to  the  highest  grade  of  idiocy. 
Epileptic  imbecility  in  many  cases  appears  in  connection  with  an 
inclination  to  commit  immoral  acts  ("epileptic  moral  insanity," 
see  (c)  Pathological  inversion  of  the  feelings  of  judgment). 

The  highest  grades  of  epileptic  idiocy  are  very  often  accom- 
panied with  paralyses,  contractures,  deformities,  sometimes  with 
complete  animalism.     In  the  meantime  various  types  of  epileptic 


218  Special  Psychiatry. 


ps}'choses,  amounting  sometimes  to  ravings  may  appear  in  this 
chronic  condition  in  connection  with  epileptic  seizures  which  ac- 
company them,  or  as  equivalents. 

2.  Paranoic  states  which  show  themselves  in  the  further 
development  of  the  above-mentioned  ideas  of  detraction,  quite 
often  connected  with  grandiose  ideas,  and  would  offer  the  type 
of  functional  paranoia  if  epileptic  seizures  did  not  interrupt  their 
course  at  intervals  and  mental  weakness  did  not  speedily  appear. 

3.  Circular  psychic  symptoms  which  show  alternately  states 
of  depression  and  exaltation,  whose  character,  moreover,  as  in 
the  above-mentioned  paranoic  conditions,  is  changed  by  the 
accompanying  epileptic  seizures  and  the  mental  weakness,  and 
is  distinguished  l3y  this  from  functional  circular  psychosis. 

The  course  of  the  chronic  epileptic  psychosis  is  very  tedious, 
often  extending  over  a  lifetime ;  the  result  is  death,  which  occurs 
in  about  half  the  cases  during  the  epileptic  seizure. 

The  pathological  anatomy  of  epileptic  psychoses  in  long- 
continued  cases  shows  the  cranium  thick  and  heav}*;  adhesions 
of  the  dura  to  the  cranium  in  half  the  cases,  the  arachnoid 
thickened  and  milky;  considerable  increase  of  the  neuroglia, 
which  Bleuler  considered  as  an  increased  growth  of  the  glia 
fibers  lying  between  the  pia  and  the  outermost  tangential  nerve 
fibers  (diffuse  subpial  gliosis)  ;  atrophy  of  the  frontal  and 
parietal  convolutions.  "Whether  the  changes  at  the  cornu  am- 
monis  are  somewhat  characteristic  of  epilepsy  (Meynert,  Bratz), 
further  researches  must  teach. 

The  treatment  demands  the  treatment  of  the  basic  disease. 
Only  the  bromide  preparations  and  atropin  are  remedies  which 
should  be  considered.  Of  the  first,  one  should  administer  once 
a  day  (best  in  the  evening)  from  four  to  five  to  six  grams  in 
considerable  liquid  (one  may  connect  it  with  small  doses  of  digi- 
talis, 0.01  gram ;  the  last  should  be  used  subcutaneously  in  doses 
from  0.0003  to  0.0006.  one  to  two  times  daily.  In  status  epilep- 
ticus  chloral  clysters  are  of  advantage,  two  to  three  grams. 

A  continuous  watch  is  necessary  symptomatically.  The 
raving  epileptics  belong  to  the  most  dangerous  insane  patients, 
and,  besides  this,  need  constant  watching  on  account  of  the 
woimds  which  they  receive  during  the  seizures. 


Tlie  JTysleric  Psychoses.  219 


2.  The  Hysteric  Psychoses.^ 

Hysteria  slioivs  two  psychic  peculiarities  as  essential  symp- 
toms: first,  abnormal  irritability;  second,  heightened  suggesti- 
bility (Jolly). 

There  may  arise  on  the  basis  of  hysteria : 
•  (a)   Acutely  running  psychoses  as  pre-  or  post-hysteric  or 
as  equivalents  of  the  hysteric  attack. 

(b)  Subacute  and  chronic  mental  diseases,  hysteric  psy- 
choses.    Finally, 

(c)  The  symptoms  of  hysteria  appear  often  coincidentally 
with  another  psychosis. 

To  («).  Sometimes  twilight  states  of  longer  or  shorter 
duration  precede  a  hysteric  attack — like  those  just  before  the  epi- 
leptic seizure.  A  similar  condition  may  show  itself  after  the  at- 
tack. But  the  following  type  is  often  oljserved  here:  After 
convulsions  of  laughter  or  weeping,  marked  motor  unrest,  where 
the  patient  turns  around  in  a  circle,  turns  somersaults,  makes 
clownish  motions,  or  assumes  an  opisthotonos;  the  symptoms  of 
the  agitated  form  of  delirium  hallucinatorium  appear  with  rav- 
ing excitement  or  a  cataleptic  or  katatonic  state  where  the  body 
seems  motionless,  the  patient  like  a  statue  with  open  mouth. 
Sometimes,  also,  especially  in  children,  a  childishly  joyful  frame 
of  mind  develops  with  affected  babblings,  motor  excitement,  an 
inclination  to  injure  or  destroy  things,  as  a  supplement  to  an  at- 
tack (Fiirstner). 

The  equivalents  of  a  hysteric  attack  appear  either  under  the 
type  of  a  delirium  hallucinatorium  with  general  restlessness, 
clownism,  and  the  like,  often  also  under  the  type  of  one  of  those 
states  of  clouded  consciousness  which  have  been  described  as  tAvi- 
light  state,  stupor,  raving. 

Visual  hallucinations  appear,  Avith  these  mostly  in  the  form 
of  devils  or  animals  seen  in  motion,  which  sometimes  wander 
from  the  normal  toward  the  anesthetic  or  hyperesthetic  side. 
One  may  sometimes  invert  the  direction  by  transfer  (Charcot). 


^Moravsik.  Das  hysterische  Irresein.  Zeitschrift  fiiv  Psychiatrie, 
vol.  50.  Fiirstner.  Archiv  fur  Psychiatrie,  xxxi.  Gasiier.  Archis^ 
fill  Psychiatrie,  xxx. 


220  Special  Psychiatry. 


States  of  ecstasy,  also,  are  observed  here.  Sometimes  such  con- 
ditions are  accompanied  by  attempts  at  suicide. 

Further,  there  are  peculiar  twilight  states  in  hystericals, 
with  hallucinations  of  vision  and  audition  and  contemporaneous 
analgesia,  in  which  the  patient  gives  the  most  nonsensical  answers 
to  the  simplest  questions  and  behaves  like  a  silly  child.  Ac- 
cordingly the  patient  makes  the  impression  of  simulation  (G-an- 
ser).  Such  an  attack  may  last  several  months  (Jolly).  Fur- 
ther, narcoleptic  states  and  somnambulism,  in  which  a  double 
personality  may  develop,  may  be  mentioned  as  equivalents  for 
the  hysteric  attack. 

To  (h).  The  subacute  or  chronic  hysteric  psychosis  may 
appear : 

1.  As  an  inclination  to  immoral  actions  (hysteric  moral 
insanity),  where,  generally,  the  intelligence  is  not  essentially  dis- 
turbed and  the  memory  remains  good.  Besides  the  somatic  hys- 
teric symptoms,  there  is  a  constant  imj)ulse  to  make  trouble  at 
home,  to  insult  women,  to  injure  the  housemaids  physically,  to 
lose  the  feelings  of  decency,  to  make  false  accusations,  to  steal, 
to  set  incendiary  fires,  and  an  impulse  to  lying  which  dominates 
the  whole  type. 

2.  With  the  symptoms  of  delirium  hallucinatorium,  which 
generally  appear  in  the  agitated  form  and  in  the  condition  de- 
scribed above. 

3.  As  a  maniacal  state,  increasing  to  raving,  with  erotic, 
sometimes  religious  delusions.  The  accompanying  hysteric 
phenomena,  especially  the  sensibility  to  external  impressions, 
will  easily  distinguish  it  from  typical  mania. 

4.  As  melancholic  depression,  which  develops  quite  often  in 
hystericals.  It  is  distinguished  from  typical  melancholia  by 
being  easily  influenced,  the.  sorrow  is  not  so  deep ;  sometimes  it 
makes  the  impression  of  being  artificial,  as  if  the  patient  did  not 
take  it  so  seriously  as  he  states. 

5.  As  a  paranoic  symptom-complex.  In  hystericals  the 
delusions  develop  especially  as  religious  or  erotic.  In  regard  to 
the  first,  religious  upheavals  with  alleged  miracles  and  awaken- 
ing of  the  dead,  revivals,  epidemic  pilgrimages  should  be  men- 
tioned. The  delusion  of  Jealousy  plays  a  considerable  part  in 
the  ideas  of  an  erotic  nature. 


The  Hysteric  Psychoses.  221 

To  (c).  Hysteric  symptoms  sometimes  appear  in  imbe- 
ciles, in  acute  psychoses  (mania,  melancholia,  circular  psychoses, 
also  in  paranoia),  especially  if  they  come  on  at  the  time  of 
puberty  or  in  the  climacteric.  They  also  accompany  certain  in- 
toxication psychoses  (morphinism,  alcoholism),  especially  Avhen 
these  have  arisen  on  the  basis  of  hysteria. 

In  some  of  the  so-called  hystero-epileptic  psychoses  the 
fundamental  disease  is  epilepsy;  to  this  are  added  hysteric  phe- 
nomena. In  other  cases  there  is  only  hysteria,  and  the  severe 
attacks  in  which  a  loss  of  consciousness  appears,  and  which  give 
the  impression  of  epilepsy,  are  only  hysteric. 

*   Special    Symptomatology. 

Hallucinations.  Hallucinations  of  vision  are  frequent  in 
hysteric  psychoses,  those  of  audition  not  so  common.  Hallu- 
cinations of  taste  and  smell  are  sometimes  observed  as  agreeable, 
not  repulsive,  deceptions  of  the  senses.  The  special  direction 
of  the  delusions  has  been  already  mentioned  above,  but  there  are 
no  characteristic  delusions  for  the  hysteric  psychosis.  The  mem- 
ory of  these  patients  is  apt  to  be  good,  yet  it  is  more  or  less 
troubled  by  many  disturbances,  especially  by  twilight  states, 
states  of  delirium  hallucinatorium.  Sometimes  the  memory  is 
Aveakened  in  the  other  forms,  and  the  recollection  is  often  af- 
fected by  phantastic  ornaments. 

The  sexual  feelings,  whose  pathological  heightening  is  often 
regarded  as  a  sign  of  hysteria,  are  not  changed  in  many  cases 
qualitatively  nor  quantitatively;  quite  often  the  sexual  excita- 
bility is  depressed  (Fiirstner).  The  relations  of  love  which 
are  connected  with  them  arise  generally,  not  from  sexual  ex- 
citement, but  from  the  morbid  desire  to  injure  their  consorts, 
their  parents,  and  others. 

The  sensorial  nerves.  While  a  pathological  hypesthesia,  and 
even  anesthesia,  of  the  sense  impressions  is  quite  common  during 
hysteria  in  single  sensory  nerves  (hysteric  amaurosis,  hysteric 
deafness,  ageusia,  anosmia),  a  Iwperesthesia  of  the  affected 
nerves  exists  in  the  majority  of  hystericals.  This  hyperesthesia, 
which  may  extend,  to  the  entire  sensory  nerve  system,  becomes 
then  the  cause  of  hypochondric  complaints. 


222  Special  Psychiatry. 


With  the  disturbances  of  the  sensibility  are  connected 
spasms  and  paralyses  of  the  most  diverse  forms,  as  they  are  de- 
scribed more  fully  in  the  study  of  hysteria.  Among  the  spasms 
are  especially  frequent  the  rhythmic  spasms  of  the  respiratory 
muscles  in  hysteric  psychoses.  As  taught  in  neuropatholog}^ 
the  sufferings  of  hystericals  are  distinguished  by  susceptibility 
to  the  influence  of  other  persons  and  by  change  of  environment 
(suggestibility).  This  is  true  of  all  pathological  psychic  phe- 
nomena in  hystericals  and  quite  often  furnishes  a  valuable  symp- 
tom for  diagnosis. 

From  this  suggestibility  results  the  ever-changing  disposi- 
tion of  hystericals. 

Etiology.  "While  hysteria  in  men  is  not  uncommon,  hys- 
teric psychoses  appear  in  them  only  exceptionally.  On  the  other 
hand,  the  t}'pe  of  the  hysteric  psychosis  is  often  seen  in  boys, 
especially  at  the  time  of -puberty.  The  hysteric  psychoses  are 
most  frequently  observed  in  females;  here  they  appear  at  every 
age,  but  especially  at  puberty  and  in  the  climacteric.  The  im- 
mediate cause  for  an  outbreak  of  the  psychosis  in  hysteric  pa- 
tients is  formed  in  many  cases  by  a  psychic  trauma:  chagrin, 
sorrow,  care,  injured  love,  terror,  railroad  accidents,  and  other 
insults. 

Duration.  Hysteric  psychoses  generally  run  a  subacute 
course,  if  we  do  not  regard  the  pre-  and  post-h3'steric  attacks 
and  the  equivalents.     The  result  in  most  cases  is  recovery. 

The  diagnosis  of  a  hysteric  psj'chosis  is  assured : 

1.  By  the  anamnesia.  Development  of  the  psychosis  from 
a  hysteric  attack  or  a  j)revious  clearly  defined  hysteria. 

2.  By  the  psychic  image  which,  as  in  hysteria  itself,  shows 
lively  changes  of  s}'mptoms,  and  above  all  a  considerable  suscep- 
tibility. With  this  appear  "the  extraordinary  ease  and  rapidity 
with  which  psychic  states  are  active  in  many  physical  disturb- 
ances, whether  it  be  anesthesia  or  paresthesia,  movements  of  ex- 
pression, spasms,  or  anomalies  of  secretion"  (Kraepelin). 

3.  By  the  accompanying  somatic  phenomena,  as  they  have 
just  been  described,  clownism,  opisthotonos.  The  reflex  pupil- 
rigidity,  whose  presence  was  formerly  regarded  as  a  proof  against 
the  hysteric  nature  of  a  condition,  may  also  appear  in  hysteric 
attacks    (Westphal,  Karplus),     Finally   it  should  be   observed 


The  Hysteric  Psychoses.  223 

that  hysteric  psychoses  show  in  a  remarkable  manner  an  inverse 
type  of  the  body  temperature,  generally  very  low :  Axillary  tem- 
perature in  the  morning  98.5°  F.,  in  the  evening  97°  F. 

4.  Sometimes  a  hysteric  attack  may  be  checked  in  hysteric 
psj'choses  by  pressing  upon  a  certain  point  (at  the  left  near  the 
superior  cervical  vertebrte  or  over  the  ovarian  region). 

One  should  consider  in  the  differential  diagnosis : 

1.  Epilepsy  with  the  mental  disturbances  developing  from 
it.  Here  the  anamnesia  decides  the  observation  of  the  hysteric 
attack  with  its  peculiar  symptoms  as  opposed  to  the  epileptic, 
and,  finally,  the  suggestibility  which  is  absent  in  the  epileptic. 

2.  The  organic  psychoses  are  distinguished  from  the  hys- 
teric by  the  characteristic  symptoms  of  the  organically  condi- 
tioned paralyses,  anesthesias,  contractures,  as  opposed  to  the 
hysteric  which  may  be  present. 

Finally,  in  regard  to  the  diagnosis,  as  already  mentioned, 
one  should  observe  that  the  hysteric  symptoms  are  sometimes 
associated  with  other  psychoses. 

The  prognosis  of  the  hysteric  psychoses,  on  the  whole,  is 
favorable;  relapses  are,  however,  frequent.  Many  cases  pass 
over  into  terminal  dementia. 

The  treatment  aims  at  curing  the  hysteria  as  the  basis  of  the 
psychosis.  Isolation  is  the  first  requisite  in  all  hysteric  psy- 
choses (hence  admission  to  an  institution  is  advisable,  and  ab- 
solute rest  in  bed  is  recommended).  Even  in  the  institution  it 
is  best  to  isolate  the  patients.  For  the  many  cases  where  the 
nutrition  is  impaired,  a  tonic  treatment  is  recommended. 
Finall}^,  the  mental  disturbances  should  be  treated  symptomati- 
cally. 

The  oft-recommended  operations  on  the  female  genital  or- 
gans should  be  rejected  and  are  only  indicated  where  disease  of 
those  organs  is  present,  which  would  demand  an  operation  with- 
out reference  to  the  psychosis.  But  even  in  such  cases  it  is 
better  to  postpone  the  operation  till  after  the  cure  of  the  psy- 
chosis, unless  there  is  a  pressing  vital  indication. 


224  Special  Psychiatry. 


3.  The  Choreic  Psychoses.^ 

(a)  The  Chorea  of  Sydenham. 

Easy  irritability,  changes  of  the  disposition,  deterioration  of 
the  memory,  inclination  to  wayAvardness,  sluggishness  are  the 
pathological  psychic  phenomena  which  regularly  accompany 
chorea. 

In  a  proportionally  small  percentage  of  the  cases  of  chorea 
a  mental  disease  develops  which  runs  in  a  majority  of  the 
cases  under  the  type  of  a  delirium  hallucinatorium,  with  marked 
motor  unrest  and  violent  choreic  movements.  It  seldom 
reaches  maniacal  excitement  (Jolly),  developing  directly  from 
the  choreic  motor  unrest. 

Chorea  minor  is  to  be  distinguished  from  chorea  major,  in 
which  there  is  severe  hysteria  with  hysteric  attacks. 

The  choreic  psychosis,  as  a  rule,  terminates  in  recovery. 
Only  exceptionally  does  it  lead  to  death,  especially  in  the  chorea 
of  pregnancy,  from  exhaustion  and  complications,  e.g.,  in  pre- 
mature birth. 

The  treatment  calls  for  rest  in  bed,  abundant  nutrition;  in 
very  great  motor  unrest,  antipyrin,  three  times  daily,  0.5  to  1 
gram  is  recommended,  in  very  severe  cases  chloral  hydrate  per 
klysma. 

(b)   Chronic   Progressive   Chorea. 2 

Chronic  progressive  chorea  leads,  in  the  majority  of  cases, 
to  an  irritability  of  the  patient  which  is  connected  with  a  gradual 
weakening  of  the  mental  power :  sometimes,  intercurrent  para- 
noic states  appear  also,  with  or  without  hallucinations. 

Exceptionally  a  paresis  (Mendel,  Wollenberg)  develops 
from  chronic  progressive  chorea. 


'^Mobius.  Seelenstorun,£ren  bei  Chorea.  Xeurologisehe  Beitrage  II. 
Ziim.    ArcMy  fiir  Psychologie..  vol.  27. 

-  Ladame.  Des  troubles  psychiques  dans  la  choree  degenerative. 
Ai-chives  de  Neui'ologie,  1900,  fevrier. 


The  Intoxication  Psychoses:  Auto-intoxication.         '2'2b 

IV.  THE  PSYCHOSES  OF  INTOXICATION. 

We  distinguish : 

1.  Ps}X'hoses  which  arise  from  a  toxin  generated  within  the 
body  itself :    endogenous  psychoses,  autointoxication  psychoses. 

2.  Such  as  are  developed  from  a  toxin  introduced  into  the 
body  from  without,  exogenous  psychoses,  and  among  these  last 
are  such  as  arise  from  infection;  infection  psychoses,  such  as 
are  called  forth  by  organic  poisons;   and 

3.  Such  as  are  called  forth  by  inorganic  jJoisons. 

1.  Autointoxication  Psychoses.    Endogenous  Psychoses. 

(A)  Psychoses  Brought  Forth  by  a  Disturbance  or  Suppression 
of  the  Function  of  the  Thyroid  Glands. 

Experiments  on  animals  and  men  whose  thyroid  glands 
have  been  removed  (operative  myxedema,  Eeverdin,  Kocher) 
have  shown  that  the  function  of  the  thyroid  gland  is  of  the  great- 
est importance  to  the  economy  of  the  entire  body.  Yet  it  is 
questionable  at  "present  whether  the  pathological  phenomena, 
appearing  after  the  cessation  or  pathological  change  of  the  func- 
tion of  the  thyroid  gland,  are  produced  because  a  toxin  arising 
from  metabolism  is  not  neutralized,  or  because  the  fluid  pro- 
duced in  the  thyroid  gland  is  absent  in  the  metabolism,  or,  finally, 
if  both  factors  work  together. 

(a)  Infantile  Myxedema.^     (Idiotia  Myxedematosa, 
Sporadic  Cretinism.) 

The  injuries  to  the  thyroid  gland  which  call  forth  myxe- 
dema may  afPect  the  child  before  birth  or  in  the  first  years  of 
life.  The  symptoms  of  myxedema  consist  essentially  in  retarda- 
tion of  the  somatic  and  mental  development.  The  growth  is 
that  of  a  dwarf.  The  patient  remains  very  small.  The  height 
of  the  Pascha  of  the  Bicetre  was  90  centimeters  at  19  3^ears.  A 
child  of  7%  years  whom  I  myself  observed  was  49  centimeters 
in    height.     The    bone    formation    is    defective.     Examination 


Busclian.    Ueber  Mvxodem  und  venvandte  Zustiinde.     1896. 

15 


226  Special  Psychiatry. 


with  the  Eontgen  rajs  shows  defect  of  the  ossification  points 
of  the  epiph5'ses.  In  opposition  to  tliis,  hyperplastic  chondro- 
dj'strophia  is  found  in  rhacliitis.  The  cutis  is  thickened,  dry, 
of  a  yellowish  color,  the  eyelids  are  slit-shaped,  the  lips  puflEed 
and  everted,  the  nose  is  thick,  depressed,  the  cheeks  are  like 
wax,  pale  with  red  flecks.  On  the  chin  and  neck  there  are 
m5'xedematous  tumors,  also  above  the  clavicle  and  especially  on 
the  volar  side  of  the  first  phalanges  of  the  fingers.  The  hair  is 
scant  or  entirely  wanting;  in  many  cases  even  the  down  has  dis- 
appeared. The  teeth  are  carious,  the  neck  is  short  and  thick, 
the  clitoris  is  generally  enlarged,  the  thyroid  gland  cannot  be 
palpated,  the  pulse  is  slow,  the  temperature  habitually  subnor- 
mal. The  movements  of  the  patient  are  generally  clumsy,  the 
gait  often  waddling. 

The  mental  capaliilities  develop  very  slowly.  Children  of 
twelve  to  fourteen  years  are  equal  in  intelligence  to  those  of 
one  to  two  years.  Yet  there  are  exceptions  in  which  the  in- 
tellect suffers  but  little.  Speech  develops  only  very  defectively, 
has  often  a  squealring  and  whimpering  character.  The  nature 
of  these  children  is  generally  friendly  and  trustful.  Sometimes 
epileptic  or  epileptiform  seizures  are  observed  in  the  first  years. 

Brissaud  has  described  this  condition  under  the  name  of 
myxedematous  infantilism,  in  which  the  somatic  and  mental 
peculiarities  of  childhood  remain  till  advanced  age.  The  path- 
ological t}-pe  is  composed  of  the  large  head,  elongated  body, 
prominent  abdomen,  rudimentary  sexual  organs  sparsely  cov- 
ered with  hair,  mammary  glands  slightly  developed,  defective 
intelligence,  rapid  and  abnormal  entrance  as  well  as  traeeless 
vanishing  of  strong  emotions.  Alcoholism  of  parents,  heredi- 
tary syphilis,  tuberculosis,  and  bad  nutrition  should  be  regarded 
as  etiological  factors.  Between  this  infantilism  and  myxe- 
dematous idiocy  there  are  gradual  transitions. 

Dia gliosis. — Myxedematous  idiocy  is  distinguished  from 
idiocy  by  the  absence  of  the  somatic  symptoms,  and  from  fetal 
rhachitis  both  by  the  lack  of  disturbances  of  the  intelligence, 
and  by  the  peculiar  qualities  of  the  bones  which  have  been  men- 
tioned above. 

The  treatment  of  myxedematous  idiocy  consists  in  admin- 
istering thyroid  tablets  of  0.3  grams  (preparation  of  Borroughs, 


The  Inloxicaiion  Psychoses:  Aulo-iitluxicaiion.         227 

Welcome  &  Co.).  One  to  three  such  tablets  daily  for  a  month; 
they  are  then  suspended  or  given  in  smaller  doses,  and  then  be- 
gun again.  Care  should  be  taken  that  the  body  weight  does 
not  decrease  too  rapidly,  that  there  is  no  abnormal  acceleration 
of  the  pulse  or  rise  of  temperature,  that  no  collapse-like  or 
stenocardiac  states  appear,  in  which  cases  the  tablets  should 
be  discontinued  or  the  dose  diminished. 

(b)  The  Myxedema  of  Adults  (Pachydermic  Cachexia)  ^ 

arises  from  a  disease  of  the  thyroid  gland,  e.g.,  by  excessive  em- 
ployment of  iodine  or  from  the  surgical  removal  of  the  thyroid 
gland  (myxedema  operativum). 

The  somatic  phenomena  are  the  same  as  those  which  have 
just  been  described  in  infantile  myxedema,  so  far  as  the  con- 
dition of  the  cutis,  its  adnexa,  the  pulse,  and  the  temperature 
are  concerned.  In  regard  to  the  mental  condition,  the  difficulty 
of  thought  and  action,  the  marked  depression  of  the  memory 
are  to  be  specially  noted.  An  apathy  of  high  degree  appears, 
so  that  the  patient  has  no  longer  interest  in  anything  and  does 
not  care  for  his  business  nor  his  family.  In  the  further  de- 
velopment, the  patients  show  the  condition  of  apathetic  idiocy. 
Sometimes  the  disease  has  a  fatal  result  with  the  appearance  of 
spasms  and  coma. 

Sometimes  further  pathological  psychic  S3miptoms  develop 
on  the  basis  of  the  retardation  of  the  psychic  functions,  espe- 
cially of  a  melancholic  nature  with  states  of  anxiety,  also  with 
hallucinations  of  the  various  senses. 

The  myxedema  of  adults  affects  especially  women  (the 
relation  to  men  is  about  four  to  one)  of  the  age  of  thirty  to 
fifty  3^ears. 

The  treatment  is  the  same  as  in  the  myxedema  of  children. 
It  causes  both  the  somatic  symptoms  and  psychic  abnormalities 
to  disappear.     One  should  administer  three  to  five  tablets  daily. 

(c)   Cretinism. 2 

Cretinism  is  an  endemic  idiotism  with  definite  somatic 
changes.     These  consist  essentially  in  the  backwardness  of  the 


'  Pilcz.    Jahrbuch  fiir  Psychiatrie,  1901,  77. 
-Allara.     Der  Cretiiiismus.     Leipzig,   1894. 


228  Special  Psychiatry. 


osseous  development,  hyper troph}-.  of  tlie  soft  parts,  and  disease 
of  the  thyroid  gland. 

Cretins  are  divided  according  to  degree: 

1.  Into  typical  cretins,  who  possess  neither  intellectual  capa- 
bilities, articulate  speech,  nor  power  of  propagation. 

2.  Into  atypical  cretins,  who  possess  limited  individual 
capabilities  which  concern  essentially  the  satisfaction  of  bodily 
wants. 

3.  Into  the  cretinous,  who  may  be  encouraged  to  do  manual 
labor,  may  learn  easy  handicrafts,  but,  with  this,  are  mentally 
weak  and  often  show  a  tendency  to  immoral  actions. 

The  intelligence  of  the  cretin  shows  all  degrees,  from  a 
slight  grade  of  weakmindedness  to  the  highest  development  of 
idiocy.  The  higher  grades  belong  as  a  rule  to  the  apathetic  form 
of  idiocy. 

Epilepsy  and  spasms  are  seldom  observed  in  cretins. 
Often,  however,  there  is  a  periodic  suspension  of  all  mental 
activity  for  several  hours. 

The  speech  of  the  cretin  is  but  little,  if  at  all,  developed. 

The  cranium  shows  a  great  breadth  at  the  root  of  the  nose, 
strikingh'  small  development  of  the  base  of  the  skull,  and  great 
arching  of  the  occiput.  The  cause  of  this  formation  of  the 
cranium  is  that  the  phenobasilar  s^Tichondrosis,  which  under 
normal  conditions  remains  till  the  fifteenth  year,  becomes  ossi- 
fied prematurely  (Aarchow). 

The  hypertrophy  and  growth  of  the  soft  parts  are  shown 
in  the  face,  trunk,  and  extremities,  and  resemble  in  many  ways 
the  myxedematous  tumors. 

The  thyroid  gland  in  most  cases  is  enlarged,  most  fre- 
quently in  the  middle  lobe. 

Development  of  the  genital  organs  of  the  cretin  usually 
stops  at  the  stage  of  childhood.  The  menses  are  absent  or  are 
irregular. 

Etiology.  In  Germany  we  still  find  cretinism  in  the  Jura 
Mountains  and  the  Yosges.  It  is.  however,  becoming  rarer, 
thanks  to  modern  methods  of  sanitation.  In  Austria  it  is  found 
around  Salzburg,  in  Steiermark,  Tyrol;  in  Switzerland,  in  the 
Cantons  "VTallis,  I7ri,  "Waadt :  in  Italy,  in  Piedmont.  Lomb^rdy, 
Yenetia;  in  France,  in  Savoy  and  the  Pyrenees.     (In  Austria, 


The  Intoxication  Psychoses:  Auto-intoxication.         229 

17,393  cretins  were  reported  altogether,  in  1893,  that  is,  11  to 
100,000  inhabitants). 

Cretinism  is  found  more  frequently  in  males  than  in 
females. 

The  cause  of  cretinism  is  to  be  found  in  faulty  drinking 
water.  The  specific  injurious  quality  is  unknown.  It  is  to  be 
assumed  that  this  drinking  water  disturbs  the  functions  of  the 
thyroid  gland,  and  that  this  disturbance  is  the  cause  of  cretin- 
ism. The  course  of  cretinism  is  chronic;  generally,  cretins  do 
not  reach  an  advanced  age.     The  prognosis  is  unfavorable. 

The  treatment  is  prophylactic,  looking  to  the  betterment 
of  the  general  sanitary  conditions  of  the  region  afEected.  Aside 
from  this,  the  thyroid  treatment  should  be  tried,  although  any 
particularly  gratifying  results  from  its  use  have  hitherto  been 
lacking. 

Where  helpless  cretins  cannot  be  cared  for  at  home,  or 
Avhere  they  are  inclined  to  violent  actions,  it  is  better  to  treat 
them  in  institutions. 

(d)   Psychoses  with  Basedow's  Disease. i 

The  disease  of  Basedow  is  classed  here,  although  it  must 
still  be  regarded  as  doubtful  whether  the  symptom-complex  of 
this  disease  rests  on  an  autointoxication,  whose  cause  is  the 
absence  or  disturbed  function  of  the  thyroid  gland,  or  a  central 
disease  of~  the  nervous  system,  and  whether  the  disease  of  the 
thyroid  glands  forms  only  a  partial  symptom  of  the  real  disease. 

The  majority  of  individuals  suffering  from  Basedow's  dis- 
ease are  irritable,  emotional ;  many  are  constantly  depressed, 
others  are  unusually  serene,  and  the  psychoses  which  develop  on 
the  basis  of  Basedow's  disease  show  in  part  the  characteristics 
of  the  hysteric  psychoses,  others  run  in  the  type  of  deliriimi  hal- 
lucinatorium ;  finally,  there  arc  melancholic  conditions  and,  more 
seldom,  paranoic  states  which  develop  in  Basedow's  disease. 
The  treatment  should  be  directed  first  to  alleviate  the  disease, 
then  to  meet  symptomatically  the  indications  arising  from  the 
special  psychic  disease. 


'  Maiiiilicim.    Der  Morbus  Gravesii.     Berlin,  1897. 


230  Special  Psychiatry. 


B.  Psychoses  Which   Come   from   the   Intestine   or  Other 
Organs  by  Autointoxication. 

It  is  assumed  that  toxins  have  been  formed  in  these  cases 
which  produce  a  poisoning  of  the  brain,  and  consequently,  a 
psychosis.  The  point  of  departure  of  this  autointoxication  may 
be  the  intestine,  and  in  this  case  the  psychosis  appears  with 
acetonuria  and  an  increased  secretion  of  indican. 

These  psychoses  usually  run  a  favorable  course,  though  there 
are  also  cases  which  rapidly  lead  to  death  under  the  type  of 
acute  delirium.^ 

Further,  toxins  with  their  injurious  influence  upon  the 
brain  may  arise  in  liver  diseases,  pulmonary  tuberculosis  (here 
especially  h3qDochoudric  depressive  states),  in  Bright's  dis- 
ease (as  a  mild  form  of  uremia,  generally  with  disturbances  of 
the  consciousness  and  spasmodic  attacks),  in  gout,  tetanus,^ 
diabetes.  Diabetic  ps3^choses^  sometimes  appear  under  the  type 
of  hallucinatory  paranoia  with  ideas  of  persecution,  sometimes 
they  are  apparently  typical  melancholias,  sometimes  they  show 
a  state  of  mental  weakness  with  paralytic  conditions,  so  that 
suspicion  may  rest  upon  a  developing  paresis. 

Sometimes  psychoses  are  observed  with  carcinoma  of  the 
various  organs.* 

Many  of  the  psychoses  which  belong  under  this  head  run 
acutely  under  the  type  of  delirium  hallucinatorium,  yet  fre- 
quently states  of  depression  Avith  a  hypochondric  character 
also  appear;  in  this  manner,  also,  states  of  mental  weakness  are 
observed. 

The  treatment  must  above  all  fulfill  the  causal  indications; 
in  regard  to  psychoses  arising  from  the  intestine  we  recommend 
calomel  (0.3  to  0.5  gram  calomel,  divided  in  ten  pills,  which 
should  be  taken  during  the  day),  or  iodoform  in  doses  of  1  gram, 
also  divided  into  ten  pills  (v.  Wagner).     ■ 


^  V.  Solder.     Jahrbuch  fiir  Psychiatrie,   1898. 
-Luther.     Zeitschrift  fiir  Psychiatrie.  1901,  Iviii. 
^  Laiidenheimer.     Berliner  klinische  Wochenschrift,  1898. 
^Elzholz.     Jahrbuch  fiir  Psychiatrie,  1898. 


The  Intoxication  Psychoses:  Infection.  231 


2.  Psychoses  Which  Are  Called  Forth  by  Poison  Introduced 
Into  the  Body  from  Without  (Exogenous  Psychoses). 

(a)   Psychoses    Brought    on    by    Infectious    Diseases. 
Infection    Psychoses.^ 

It  is  doubtful  whether  the  infectious  disease  calls  forth  the 
psychosis  per  se.  What  is  more  probable  is  that  in  the  course 
of  the  infectious  disease,  toxic  substances  are  generated  in  the 
body,  which  condition  the  psychosis  after  the  termination  of  the 
phj^sical  disease.  The  initial  deliria  in  the  infectious  diseases 
speak  for  the  origin  of  pathological  psychic  phenomena  by  pri- 
mary intoxication. 

They  begin  usually  with  profound  disturbance  of  the  con- 
sciousness and  numerous  sense  deceptions.  Their  content  often 
heightens  the  state  of  anxiety  to  raving  excitement. 

The  same  is  essentially  true  of  the  deliria,  which  sometimes 
are  so  heightened  at  the  climax  of  the  fever  that  the  patient  gives 
the  impression  of  being  insane. 

Such  cases  of  initial  and  fever  deliria  come  to  the  notice  of 
the  psj^chiatrist  only  when  the  diagnosis  is  erroneous  (the  men- 
tal disturbance  masks  the  general  disease)  or  in  epidemics  oc- 
curring in  institutions. 

In  typhoid  the  initial  deliria  sometimes  precede  the  well- 
defined  somatic  symptoms,  and  disappear  with  the  increasing 
fever. 

The  deliria  present  at  the  height  of  the  fever  generally 
disappear  with  its  decadence.  In  many  cases  there  is  a  collapse 
delirium,  with  great  confusion  and  massive  hallucinations  (de- 
lirium hallucinatorium). 

The  greatest  number  of  infection  psychoses^  develop  after 
the  termination  of  the  fever  and  at  a  time  when  one  expects  con- 
valescence. Sometimes  the  hallucinations  are  transferred  from 
the  febrile  to  the  stage  of  convalescence  and  to  the  psychosis. 
Sometimes  they  form  the  nucleus  around  which  the  future  in- 
sanity crystallizes. 


^Kraepelin.     Archiv  fiir  Psychiatrie,  xi,  page  161. 
^  Adier.     Zeitschrift  fiir  Psychiatrie,  vol.  liii. 


232  Special  Psychiatry. 


The  diseases  which  are  specially  concerned  here  are  influ- 
enza/ t3'phoid  fever,  dysentery,  articular  rheumatism,  pneu- 
monia, cholera,  diphtheria,  leprosy,"  erysipelas,  variola,  whoop- 
ing-cough.^ 

The  psychoses  following  typhoid  fever  are  distinguished  by 
great  jjrostration.  They  appear  in  many  forms,  as  do  the  in- 
fluenza psychoses.  The  psychoses  under  the  type  of  delirium 
hallucinatorium  are  especially  frequent.  In  the  second  place 
are  the  depressive  forms,  especially  melancholic  mental  dis- 
turbances, rarely  the  maniacal  forms,  still  more  rarely  acute 
dementia.  An  acoholic  delirium  or  hysteric  psychoses  often  de- 
velop after  infectious  diseases.  The  outcome  of  the  infection 
psychoses  is  generally  favorable;  there  is  also  a  transition  into 
chronic  paranoia  and  terminal  dementia. 

Hitherto  there  has  been  no  pathological  anatomy  of  these 
psychoses. 

Under  the  name  of  Korsalcoff's  psychosis  (Jolly),  a  peculiar 
form  of  infection  psychosis,  first  described  by  Korsakoff,  is  desig- 
nated, which  is  associated  in  the  majority  of  cases  with  a  multi- 
ple neuritis  (the  psychic  sjonptom-complex  is  also  observed  with- 
out neuritis),  especially  in  alcoholists,  but  is  also  observed  with- 
out alcoholism  in  various  infectious  diseases  like  typhoid  fever, 
syphilis;  sometimes,  also,  it  arises  through  traumata  of  the 
cranium. 

The  first  stage  of  the  disease  is  generally  formed  by  the 
S}Tidrome  of  multiple  neuritis  with  dullness  and  paresthesia  in 
the  hands  and  feet,  with  pareses  especially  in  the  legs,  atrophy 
of  the  muscles,  and  change  of  the  electrical  reaction;  in  severe 
cases  degenerative  reaction,  pain  in  the  peripheral  nerve  trunks 
on  pressure,  weakening  or  even  disappearance  of  the  tendon  re- 
flexes. Avith  grave  gastric  disturbances  and  acceleration  of  the 
pulse  Avith  undisturbed  visceral  reflexes  are  noted.  In  other 
cases  the  symptoms  and  discomforts  of  polyTieuritis  are  so  slight 
that  the  disease  seems  to  commence  with  a  delirious  condition  of 


^  Friedliinder.  Ueber  den  Einfluss  des  Typhus  abdominalis  auf  das 
Ker\'ensystem.     Berlin.  1901. 

^Max  Laehr.  Die  nervosen  Krankheitserscheinungen  der  Lepra. 
Berlin,  1899. 

^  May.     Arcliiv  fiir  Kinderheilkunde,  1901,  neuritis  multiplex. 


The  Intoxication  Psychoses:  Ergot.  233 

tliG  jDaticnt,  giving  the  impression  of  an  alcoholic  delirium,  but 
in  which  the  neuritic  phenomena  are  manifest  on  examination. 
Sometimes  a  stuporous  state  supervenes  instead  of  this  delirium. 

The  psychic  disturbances  which  characterize  the  following 
stage  of  the  disease  show  much  disorientation  as  to  time  and 
place,  with  very  striking  disturbances  of  the  memory,  Avhich  are 
partly  amnesic  (also  with  retroactive  amnesia),  partly  par- 
amnesic.  The  patient  is  considerably  disturbed  in  his  attention, 
forgets  immediately  or  after  a  few  moments  what  was  just  said 
or  has  just  taken  place,  and  he  replaces  events  of  his  former  life, 
where  his  recollection  fails,  by  images  which  he  has  obtained, 
partly  by  dreams,  partly  by  hallucinations,  partly  by  the  fantas- 
tic transformation  of  momentary  perceptions.  From  this  comes 
much  confabulation,  incoherent  narratives,  histories  of  robbers. 

The  course  of  this  disease  is  habitually  protracted.  Hallu- 
cinations and  loss  of  memory  gradually  decrease.  Sometimes 
paralyses  of  the  nerves  (abducens)  and  muscles  of  the  eye, 
nj'stagmus,  paresis  of  the  velum  palati  appear.  The  result  is 
generally  a  recovery,  often  after  a  year  and  longer;  in  many 
cases  a  state  of  mental  weakness  develops,  in  others  a  paranoic 
symptom-complex;  finally,  death  may  follow. 

In  regard  to  the  diagnosis,  paresis  should  be  considered 
before  everything  else.  Here  the  development  of  the  disease, 
which  is  much  slower  in  paresis  than  in  Korsakoff's  psychosis, 
but  above  all,  the  evidence  of  the  multiple  neuritis,  which  does 
not  belong  to  the  clinical  type  of  paresis,  is  decisive. 

Treatment.  If  the  disease  has  arisen  on  the  basis  of  alco- 
holism, treatment  should  be  directed  accordingly;  otherwise,  it  is 
symptomatic. 

For  the  psychoses  which  arise  from  syphilis,  see  under  "3. 
Somatic  Causes." 

(b)   Ergotism. 1 

The  use  of  ergot  may  call  forth  psychic  diseases,  which 
arise,  with  few  exceptions,  months  after  the  acute  intoxication. 
They  begin  with  cachexia,  generally  with  epileptic  seizures,  show 
ataxia  and  disturbances  of  the  sensibility  among  the  somatic 


^  Tuczek.    Arcliiv  fiir  Psycliiatrie,  vol.  13. 


234  Special  Psychiatry. 


symptoms,  and  regularly  enter  with  melancholic  depression, 
much  numbness  and  inactivity  of  the  mental  functions.  After 
the  disappearance  of  the  pathological  psychic  symptoms,  epileptic 
seizures  often  remain  for  a  long  time;  the  patellar  reflex  may 
also  be  long  absent.  The  treatment  should  regard  the  prophy- 
laxis chiefly,  improvement  of  nutrition  and  the  general  somatic 
condition. 

(c)  Pellagra^  (Maidism,  Psychoneurosis  Maidica). 

This  disease  is  caused  by  spoiled  maize,  -which  shows  in  the 
prodromal  stage  general  distress,  fatigue  easily  brought  on,  dis- 
turbances of  digestion,  usually  with  areas  of  redness  of  the 
skin,  which  is  chapped,  cracked,  and  deprived  of  epithelium. 
The  second  stage  is  dominated  by  the  pathological  phenomena 
of  the -intestinal  tract,  and  the  third  stage  shows,  besides  disturb- 
ances of  the  nervous  system  (weakness  and  pareses,  paresthesias 
and  anesthesias,  weakening  of  the  cutaneous  reflexes  and  exag- 
geration of  the  tendon  reflexes),  a  melancholic  depression  which 
often  passes  to  the  stuporous  form. 

Here,  as  in  ergotism,  the  treatment  ■  should  be  essentially 
prophylactic. 


3.  Psychoses  Which  Are  Evoked  by  Organic  Poisons. 

(a)  Alcoholic  Psychoses.^ 

Alcohol  takes  a  very  prominent  place  in  the  etiology  of 
mental  diseases.  At  least  15  per  cent,  of  all  cases  of  insanity 
are  directly  caused  by  alcohol,  or  it  is  one  of  the  chief  causes. 
[From  careful  study  of  the  reports  of  the  Xew  York  State 
Lunacy  Commission,  1888-1902,  Krauss  found  the  proportion 
of  insanity  cases  reported  as  due  to  alcohol  in  all  the  Xew  York 
State  hospitals  a  trifle  less  than  9  per  cent.].  \\e  distinguish 
1,  acute;  2,  subacute;  and  3,  chronic  alcoholic  psychoses. 


^  Jahrmarker.    Archiv  fiir  Psychiatrie,  1901,  xxxv. 

-Magiian.  De  ralcoolisme.  1S93.  Siemeiling.  Charite-Annalen, 
1891.  Moeli.  Statstisehes  und  Klinisches  iiber  Alcohol ismiis.  Charite- 
Annalen,  1884.  Liepmann.  Archiv  fiir  Psychiatrie,  vol.  27.  Baer.  Al- 
koholismus,  1878. 


The  Intoxication  Psychoses:  Alcohol.  235 

1.  The  Acute  Alcoholic  Psychosis  {Pathological  Drunkenness)  .^ 

Acute  alcoholic  intoxication  interests  us  here  only  so  far  as 
the  state  denominated  drunkenness  runs  an  abnormal  course. 
These  abnormal  states  of  drunkenness  arise  in  the  great  majority 
of  cases  on  the  basis  of  chronic  alcoholism,  yet,  without  this, 
acute  alcoholic  psychoses  also  appear  after  very  debilitating 
somatic  diseases  on  the  basis  of  considerable  hereditary  taint, 
in  epileptics,  after  injuries  to  the  cranium.  Very  often  it  is 
not  the  quantity  of  the  alcohol  taken  which  determines  the  ap- 
pearance of  these  abnormal  conditions,  but  rather  the  individual 
susceptibility  and  the  environment  under  which  the  poison  is 
taken.     It  may  show  itself : 

(a)  Under  the  type  of  apoplectic  drunkenness.  Death  fol- 
lows the  state  of  unconsciousness  under  the  appearance  of  a  gen- 
eral paralysis. 

(&)  As  a  convulsive  form  of  drunkenness  which  generates 
an  epileptic  seizure  and  maniacal  states  following  it,  which  may 
increase  to  raving  (mania  acutissima  ebriorum).  This  condi- 
tion is  accompanied  by  manifold,  frightful  hallucinations,  and 
often  leads  to  the  violent  destruction  of  whatever  is  near  the 
maniac. 

(c)  Twilight  states  (alcoholic  trance),  see  1.  Twilight 
states. 

The  drunken  one  appears  externally  calm,  answers  ordinary 
questions  without  delay  and  according  to  their  meaning,  hardly 
attracts  attention  to  his  common  corporeal  functions — in  short, 
he  gives  many  of  those  around  him  the  impression  that  he  is 
normal,  if  they  do  not  observe  him  closely. 

But  then  very  peculiar  actions  arise,  whether  it  is  in  over- 
stepping the  ordinary  rules  of  decency  (indecent  expressions, 
urinating  before  persons  of  the  opposite  sex),  or  in  committing 
criminal  actions  (lese  majeste,  exhibitionism,  crimes  against 
decency,  arson,  violent  actions  towards  others,  sometimes,  also, 
attempts  at  suicide). 

These  states  often  run  their  course  with  a  certain  anxietv. 


^Bonhoffer.    Die  acuten  Geisteskraukheiten  der  Gewo2ineitstrinker. 
Jena,  1901. 


236  Special  Psychiatry. 


with  delusions  of  persecution,  and  frightful  hallucinations  which 
call  forth  weeping  and  shrieking. 

In  the  majority  of  cases  during  this  condition  there  is  the 
possibility  of  mental  digression  for  a  short  time  and,  with  this, 
also,  the  possibility  of  the  interruption  of  an  action,  either  in 
contemplation  or  in  course  of  execution. 

This  is  quite  often  linked  with  recollections  of  the  patient's 
activities  and  predilections  of  the  time  anterior  to  the  darkening 
of  his  consciousness. 

Earely,  in  the  place  of  the  twilight  state,  there  is  a  state  of 
stupor,  but  sometimes  raving  and  without  the  medium  of  an  epi- 
leptic seizure,  as  mentioned  above. 

The  duration  of  a  pathological  drunkenness  may  be  a  few 
minutes,  hours,  or,  exceptionally,  a  day;  it  generally  passes 
away  in  a  deep  sleep. 

2.  The  Subacute  Alcoholic  Psychoses. 

Delirium  tremens^  the  insanity  of  the  drunlcard}  We  dis- 
tinguish four  stages  in  the  course  of  delirium  tremens : 

1.  The  first  stage  shows,  besides  gastric  disturbances,  cer- 
tain s}anptoms  of  anxiety  and  sporadic  hallucinations.  The 
patient,  however,  is  able  to  control  himself  externally  and  car- 
ries on  his  affairs. 

2.  The  second  stage  is  distinguished  by  a  triad  of  symptoms : 
1,  trembling;  2,  insomnia;  3,  delusions  with  sense  deceptions. 
The  patient  may  recover  from  this  stage  in  a  few  days  or  weeks. 

The  tliird  stage  develops  with  great  agitation,  violent  ac- 
tions with  increase  of  the  hallucinations.  The  patient  shrieks, 
quarrels,  strikes;  the  excitement  may  rise  to  the  highest  degree 
of  frenzy. 

The  fourth  stage  consists  of  epileptic  spasms,  which  gener- 
ally lead  to  death,  or  mussitating  deliria  develop,  the  pulse  be- 
comes small,  frequent,  the  temperature  rises  to  102°,  103°  F., 
death  comes  from  exhaustion.  Sometimes  it  results  suddenly 
with  symptoms  of  collapse. 

Deviations  from  this  course  are  shown  by : 

(a)   The  abortive  form  of  delirium  tremens  (Xacke)  with 


^The  name  comes  from  Tliomas  Sutton.  1813. 


The  Intoxication  Psychoses:  Alcohol.  237 

slight,  mostly  hypnagogic  hallucinations,  in  which  the  patient 
seems  very  intelligent  aiid  performs  his  accustomed  labor,  even 
though  it  may  be  interrupted. 

(/;)  Chronic  delirium  tremens  (Niicke).  The  delirium 
drags  along  for  weeks,  because  there  are  always  new  relapses 
when  one  attack  seems  to  have  run  its  course. 

(c)  Febrile  delirium  tremens  (Delasiauve).  The  alwve- 
described  foa  rth  stage  appears  after  a  short  prodromal  stadium, 
the  second  and  third  stages  are  omitted. 

(f/)  Polyneuritic  delirium  tremens,  Korsakoff's  disease 
(which  see),  {a)  Psychoses  brought  forth  by  infectious  dis- 
eases.    Infection  psychoses. 

Special  Symptomatology. 

Illusions  and  hallucinations  of  vision  appear,  as  a  rule. 
The  patient  sees  small  animals,  bugs,  frogs,  fleas  in  the  folds  of 
the  bed  clothes.  But  he  sees  large  animals,  elephants,  rhinocer- 
oses, coming  in  through  the  door.  Liepmann  observed  such 
animal  hallucinations  in  70  per  cent,  of  all  cases.  The  form  of 
these  hallucinations  is  often  connected  with  disturbances  of  the 
association  of  the  eye  muscles,  also  with  tremor  of  the  muscle  of 
Briicke,  and  is  often  accompanied  by  loss  of  the  color  sense. 
Illusions  and  hallucinations  of  audition  are  generally  of  a  ter- 
rifying nature;  the  patients  hear  themselves  abused,  insulted 
with  the  commonest  epithets,  sometimes  the  patient  hears  his 
own  thoughts  spoken.  Hallucinations  of  taste  and  smell  are 
rarer;  kinesthetic  hallucinations,  on  the  other  hand,  are  fre- 
quent. The  hallucinations  which  have  a  more  stable  character 
at  the  beginning  of  the  disease,  appear  later  with  lively  changes 
and  are  then  in  constant  agitation ;  while  they  recede  during  the 
daj'-,  they  are  especially  vivid  at  night.  Such  deliriants  offer  a 
peculiar  type;  they  seem  to  be  fully  oriented  during  the  day, 
but  tell  the  most  horrible  stories  of  robbers  whom  they  have 
seen  at  night,  of  whose  objective  reality  they  are  most  thoroughly 
convinced.  One  may  often  call  forth  the  visual  hallucinations 
by  pressure  on  the  eyeball  of  the  deliriant.  The  pressure  image 
of  Purkinje  appears  normally  as  tlie  sun,  moon,  stars  without 
connection,  but  not  terrifying  or  causing  anxiety  (Liepmann). 
One  often  observes  the  patient  standing,  as  if  really  observing 


238  Special  Psychiatry. 


the  hallucinations ;  he  declares  that  everything  suggested  is  real. 
The  capacity  of  these  deliriants  to  have  hallucinations,  especially 
visual  ones,  by  suggestion,  is  peculiar  to  them.  "There  is  a 
spider."     The  jDatient  sees  it  at  once. 

Bonhoffer  designates  as  "puzzle  hallucinations"  those  in 
■which  the  hallucinated  object,  which  the  deliriant  attempts  to 
seize,  vanishes  at  the  same  moment. 

The  delusions  are  closely  connected  with  the  hallucinations, 
and,  like  them,  are  almost  always  of  a  terrifying,  persecuting 
nature.  The  delusions  are  seldom  merged,  so  that  the  patient  be- 
lieves that  he  has  become  another  person.  However  crazy  may  be 
what  he  experiences  and  what  he  tells,  he  is  able  to  give  objective 
information  about  his  person  and  his  condition,  and  by  this  is 
easily  brought  away  transitorily  from  his  hallucinations  and 
delusions,  so  that  for  a  short  time  his  attention  may  equal  the 
keenness  of  the  normal  (Bonhoffer).  One  frequently  sees  him 
in  his  delirium  occupied  with  his  ordinary  labor  and  in  the  po- 
sition generally  taken  by  him  {delirium  of  occupation) . 

The  frame  of  mind  is,  corresponding  with  the  hallucina- 
tions and  delusions,  anxious,  fearful,  distrustful.  Many  deliri- 
ants, however,  appear  calm,  a  serenity  which  Kraepelin,  playing 
on  the  name,  has  called  gallows  humor. 

The  actions  result  from  the  sense  deceptions  and  delu- 
sions. They  often  become  violent  as  a  defense  against  enemies, 
and  quite  often  lead  to  self-injury  in  consequence  of  the  hallu- 
cinations. The  patient  walks  out  of  the  window,  which  he 
thinks  a  door;  he  jumps  from  a  bridge,  because  he  thinks  the 
railing  is  a  person  who  wishes  to  hinder  him  from  advancing 
further.  His  speech  is  difficult,  often  brad^-jDhrasic,  sometimes 
atactic,  only  very  exceptionally  is  there  a  condition  similar  to 
the  s3-llable-stumbling  of  the  paretic.  The  result  is  suicide  in 
from  five  to  ten  per  cent,  of  such  cases. 

Somatic  Symptoms. 

The  trembling  reaches  not  only  to  the  fingers,  but  is  dif- 
fused over  the  entire  body,  especially  to  the  tongue,  the  eyelids, 
the  eye-muscles.  The  trembling  is  rapid,  eight  to  ten  oscilla- 
tions per  second. 

Pareses  and  paralyses  generally  develop  only  when  a  neuri- 


The  Intoxication  Psychoses:  Alcohol.  239 


tis  is  produced  by  aleoliolisiii.  'J'he  sensory  nerves  in  the  be- 
ginning of  the  disease  show  hyperesthesias  and  paresthesias,  hitcr 
hyposthet^ias ;  in  the  great  majority  of  cases,  analgesia.'^ 

The  tendon  reflexes  are  prompt  in  new  cases,  frequently  be- 
come weak  during  the  course,  and  may  disappear  entirely  in  pro- 
nounced neuritis.  The  cutaneous  reflexes  are  generally  un- 
changed; sluggishness  of  pupillary  reaction  is  frequent,  but,  on 
the  other  hand,  the  Argyll-Eobertson  pupil  is  very  uncommon. 

Epileptic  spasms,  which  appear  in  delirium  tremens,  may 
belong  to  an  epilepsy  which  has  already  ceased  (alcoholism  is 
often  found  in  epileptics).  Sometimes  the  delirium  tremens 
begins  with  an  epileptic  seizure.  The  outbreak  is  caused  by  such 
a  seizure,  or  it  may  be  the  first  symptom  of  the  alcoholic  brain 
affection.  Finally,  epileptic  seizures  announce  the  fatal  term- 
ination. 

The  blood  shows  (recognized  by  venesection)  an  increased 
content  of  fat  (piarhemia).  The  fatty  contents  of  the  blood, 
which  amount  normally  to  2  to  21/2  per  cent.,  may  increase  to 
4  to  11  per  cent.  The  pulse  is  small,  frequent;  the  febrile  form 
of  delirium  tremens  shows  even  in  the  beginning  130  to  160  pul- 
sations to  the  minute.  The  temperature  of  the  body  shows  no 
essential  deviations  under  ordinary  circumstances.  If  it  falls 
under  96°  F.  collapse  is  to  be  feared,  and  if  it  rises  over  100°  F., 
one  must  reckon  on  a  complication  with  other  diseases  (pneu- 
monia). The  urine  often  contains  albumin  (Leipmann  found  it 
in  76  per  cent,  of  all  eases;  Hertz  found  constantly  acute  nephri- 
tis, and  considers  this  the  primary  disease).  Diaphoresis  is  reg- 
ularly increased.  Besides  these  phenomena,  in  the  great  major- 
ity of  cases,  the  common  somatic  symptoms  of  chronic  alcohol- 
ism may  be  shown,  as  atheroma  of  the  arterial  system  and  degen- 
eration of  the  muscles  of  the  heart,  fatty  liver,  cirrhotic  liver, 
and  chronic  Bright's  disease. 

Delirium  tremens  usually  attacks  men  from  thirty-five  to 
forty-five  years  old,  but  appears  also  in  children  and  old  men. 
AYomen  are  rarely  attacked  by  it;  the  mortality  lists  show  that 
for  ten  fatal  cases  of  delirium  tremens  in  men,  there  is  only  one 
in  women. 


^  Sehulz.     Neuritis  der  Alcoholisten.     Neurologisclies  Centralblatt, 

1885. 


240  Special  Psycliiatry. 


The  accidental  cause  for  the  breaking  out  of  delirium  tre- 
mens is  formed  by  taking  away  the  liquor,  the  most  diverse 
internal  diseases  (especially  pneumonia),  injuries  to  the  head, 
fractures  of  the  bones,  also  psychic  traumata  (anger  and  the 
like),  finally,  an  epileptic  seizure.  Breathing  alcohol  fumes  may 
cause  delirium  tremens,  as  well  as  the  use  of  alcohol. 

The  results  of  delirium  tremens  are : 

1.  EecoTery,  which  is  effected  either  after  a  critical  sleep 
which  may  last  from  thirt}'  to  forty  hours,  or  it  may  develop 
gradually.     Seventy-five  per  cent,  of  the  deliriants  recover. 

2.  Transition  into  chronic  alcoholism. 

3.  Death,  which,  in  Germany,  takes  place  in  about  12  to 
15  per  cent,  of  the  cases  (pneumonia,  self-inflicted  injuries,  acute 
intestinal  troubles). 

Sometimes  this  is  brought  about  by  suicide  under  the  in- 
fluence of  sense  deceptions  and  delusions. 

The  patJiological  anatomy  of  delirium  tremens  does  not 
show  special  characteristic  changes  in  the  brain.  In  severe  cases 
a  diffuse  degenerative  process,  affecting  the  cerebrum  diffusely, 
has  been  found ;  it  has  also  been  observed  in  the  cerebellum  and 
in  the  centripetal  paths.  The  central  gray  matter  shows  a  pre- 
dilection for  hjemorrhagic  infiltration  (Bonhoffer,  Monatschrift 
fiir  Psychiatrie,  vol.  v.). 

Diagnosis.     Delirium  tremens  may  be  mistaken  for: 
i  1.  DeJiria    of   exhaustion    after   acute    diseases.     Here   the 

anamnesia,   the    absence   of   characteristic   organic   changes   of 
chronic  alcoholism  is  generally  decisive.     The  same  is  true  of 

2.  Septicemic  deliria.  One  must  think  of  complications 
with  alcohol  if  there  is  an  external  wound  and  the  anamnesia 
shows  the  abuse  of  spirits. 

3.  Mania  in  which  the  hallucinations,  if  they  are  indeed 
present,  do  not  reach  the  extent  they  do  in  the  alcoholic  psy- 
chosis. 

4.  The  maniacal  stage  of  paresis,  ^  but  which  invariably 
shows  the  characteristic  paralytic  symptoms. 

In  both  the  last  cases  one  will  have  to  compare  the  compli- 
cation of  these  psychoses  with  alcoholism. 

5.  Post-epileptic  psychoses  in  the  cases  in  which  an  epileptic 


The  Intoxication  Psychoses:  Alcohol.  241 

seizure  precedes  the  delirium.     Here    stupefaction    is    apt    to 
be  greater,  and  the  chances  of  its  avoidance  less. 

Treatment.'^  The  most  important  task  of  this  is  prophy- 
laxis in  the  strife  against  alcoholism.  Of  prime  importance  in 
the  treatment  of  the  deliriant  is  the  most  careful  watching,  on 
account  of  the  dangerousness  of  the  patient  for  both  himself  and 
those  around  him;  thus  rest  in  bed  is  the  best  treatment.  In 
some  cases  it  is  possible  to  obtain  a  long  sleep  b}^  a  dose  of  3,  4 
or  5  grams  of  chloral  hydrate,  and  by  this  to  prevent  the  attack. 
Besides  this,  we  may  recommend  opium  (10  drops  every  two  to 
three  hours,  with  increasing  doses),  or  pure  opium  or  morphine; 
further,  bromide  of  potash  in  daily  doses  of  10  to  13  grams, 
zincum  aceticum  4  to  6  grams  in  180  aqua,  daily;  digitalis  in 
greater  or  less  doses,  apomorphine,  strychnine  injections  in  doses 
of  1  to  2  mg.,  or  atropine  injections  in  doses  of  I/2  to  1  mg.  In. 
some  cases  one  may  obtain  an  improvement  by  cold  shower-baths 
or  by  evoking  an  active  diuresis  by  diuretin. 

Aside  from  this,  one  may  hope  that  an  expectant  treatment 
with  baths,  cooling  drinks  and  some  alcohol  may  lead  to  re- 
covery. 

Further,  an  alcohol  psychosis  may  run  under  the  type 

(a)  Of  alcoholic  melancholia.  After  acute  excesses  there 
may  arise  on  the  basis  of  chronic  alcoholism  a  melancholic  state, 
with  self-accusations,  depressive  delusions,  corresponding  hallu- 
cinations, and  symptoms  of  stupor  which  pass  away  in  a  few 
weeks. 

(6)  Of  alcoholic  hallucinatory  paranoia."^  {Acute  hallu- 
cinosis of  the  drinTcer,  Wernicke.)  A  mania  of  ideas  of  detrac- 
tion develops,  which  is  quite  often  combined  with  megalomani- 
acal  ones.  Vivid  auditory  hallucinations  inaugurate  the  patho- 
logical type  and  play  the  most  considerable  part  in  its  course. 
Severe  injuries,  common  words  of  abuse,  threats  of  severe  punish- 
ment, constitute  the  contents  of  the  auditory  hallucinations. 
The  patient  may  also  say  that  the  voices  and  images  are  made 
to  drive  him  insane,  or  to  render  him  harmless.  The  delusions 
here  develop  especially  in  two  directions ;  on  the  one  side,  as  jeal- 


^  Fiirstner.    Zeitsehrift  fiir  Psychiatric,  vol.  xxxiv. 
='llberg.     JSeurologisches  Centralblatt,  1890,  p.  360. 

16 


242  Special  Psychiatry. 


ous  delusion,  where  quite  often  real  occurrences  are  distorted  in 
an  insane  manner  (the  wife  has  repulsed  her  husband,  who  is 
always  drunk;  she  has,  perhaps,  formed  relations  with  another), 
on  the  other  side,  the  delusions  turn  to  religion;  the  patient  be- 
lieves that  he  is  called  by  a  divine  voice  to  do  certain  things. 

"With  this,  the  patient  is  not  essentially  disturbed  in  his 
orientation,  and  often,  if  he  does  not  bring  forward  his  system  of 
mania  and  his  hallucinations,  which  mostly  affect  the  auditory 
or  visual  senses,  makes  the  impression  of  being  a  man  of  under- 
standing who  is  the  victim  of  intrigues.  Anxiety  is  almost  con- 
stantly present  with  this  condition.  The  course  of  this  paranoia 
is  sometimes  very  stormy;  often  connected  with  hallucinations 
in  all  or  almost  all  of  the  senses  with  violent  emotions  of  ap- 
prehension, and  sometimes  ends  suddenly  after  eight  days  or 
three  to  four  weeks.  In  other  cases  the  course  is  protracted  and 
lasts  six  weeks  or  a  number  of  months.  Sometimes  this  psy- 
chosis passes  over  into  incurable  chronic  paranoia. 

This  alcoholic  form  is  distinguished  from  primary  func- 
tional paranoia  by  the  emotions  in  this  being  less  reserved ;  con- 
sequently the  disposition  is  changing,  while  the  intelligence  and 
memory  are  generally  not  retained  as  in  that  primary  disease. 
The  anamnesia  and  the  organic  sjTuptoms  of  alcoholism  are  of 
diagnostic  importance. 

3.  Chronic  Alcoliolic  Psychoses. 
The  chronic  alcoholist  shows,  in  respect  to  his  mental  con- 
dition : 

1.  A  certain  degree  of  mental  weakness,  which  expresses 
itself  especially  in  lack  of  energ}-  and  limitation  of  the  judg- 
ment. 

2.  A  weakening  of  memory. 

3.  A  disturbance  of  the  moral  feelings.  Among  the  first 
symptoms  of  the  chronic  alcoholist  is  his  indifference  to  his 
own  interest,  towards  what  was  dear  and  sacred  to  him  be- 
fore, to  his  calling,  and  his  friends.  He  no  longer  recognizes 
the  scruples  which  his  social  position  imposes  upon  him,  he  loses 
the  conception  of  the  honor  of  his  station,  his  thoughts  and 
actions  are  only  for  the  gratification  of  his  passions.  From  this, 
immoral  transactions   often  result;  among  the  poorer  classes, 


The  Intoxication  Psychoses:  Alcohol.  243 

begging  and  stealing  to  buy  liquor;  among  tbe  well-to-do,  decep- 
tions, forging  checks,  and  the  like,  to  obtain  means  for  gratify- 
ing their  passion  which  labor  in  their  occupation  no  longer  fur- 
nishes. Meanwhile,  acute  and  subacute  psychoses  appear  in  the 
chronic  alcoholist  as  they  have  been  described  above,  and  which 
make  the  pathological  condition  worse. 

In  the  further  course,  a  state  of  dementia  develops,  quite 
often  complicated  with  acute  symptoms  of  fresh  intoxication. 

This  state  of  dementia,  which  may  be  connected  with  mel- 
ancholic and  hypoehondrie,  and  also  with  megalomaniaeal 
ideas,  sometimes  shows  paralytic  symptoms  also,  difficulty  in 
speaking,  inequality  of  the  pupils,  weakening  of  motility,  dis- 
turbed gait,  exaggeration  or  absence  of  the  tendon  reflexes,  so 
that  the  clinical  type  of  a  paresis  ma}^  arise  (alcoholic  pseudo- 
paresis). 

Of  diagnostic  importance  is  the  lack  of  the  paretic  disturb- 
ance of  speech,  the  reflex  rigidity  of  the  pupils,  the  anamnesia 
(misuse  of  alcohol,  lack  of  preceding  syphilis),  the  progressive 
character  (not  present,  as  a  rule,  in  alcoholic  paresis),  the 
improvement  of  the  condition  with  elimination  of  alcohol,  so 
that  apparently  incurable  conditions  of  idiocy  may  pass  into 
recovery  with  a  defect  after  a  long  and  wavering  course. 
Moreover,  the  combination  of  alcoholism  and  paresis  must  be 
considered.  Dissimulation  is  quite  frequent  in  chronic  alcohol- 
ism. Patients  deny  everything  which  may  incriminate  them, 
represent  themselves  as  innocent  victims  who  have  never  done 
anything  wrong. 

Etiology.  1.  Heredity  plays  an  important  role.  Accord- 
ing to  Lewis,  in  64  per  cent,  of  the  cases  the  father  or  the 
mother  of  the  alcoholist  was  an  alcoholist  also.  It  is  not  neces- 
sary, then,  to  think  of  a  transmission  of  the  desire  for  drink, 
but  of  an  inherited  weakness  of  the  nervous  system  or  loss  of  the 
power  of  resistance  which  causes  the  patient  to  yield  readily  to 
alcohol,  in  emulation  of  parental  example. 

2.  Imitation  of  others  in  later  life,  especially  in  certain 
occupations,  to  alcoholism  (stone  masons,  bricklayers,  and  kin- 
dred trades). 

3.  Of  special  importance  in  the  chronic  misuse  of  alcohol 
is  the  impulse  to  stimulate  the  nervous  system  after  the  use  of 


244  Special  Psychiatry. 


alcoholic  beverages  has  been  begim  by  momenta  1  and  2.  The 
vrant  of  the  ordinary  stimulus  causes  a  sort  of  mental  vacancy, 
abnormal  ^^hysical  sensations,  disagreeable  feelings. 

4.  The  use  of  alcohol  has  been  begun  by  many  through  first 
using  it  as  a  means  to  obtain  sleep  or  to  quiet  pain. 

It  is  not  known  why  one  can  consume  a  large  C[uantity  of 
alcohol  with  impunit}',  and  another  be  injured  by  the  use  of 
only  a  small  quantit}",  and  why  there  is  complete  intolerance  in 
many  individuals.  Hereditary  conditions  undoubtedly  play  a 
prominent  part  in  this  connection. 

The  results  of  chronic  alcoholism  are: 

1.  Improvement  with  inclination  to  relapses. 

2.  Incurable  mental  disease. 

3.  Death  by  organic  changes  which  alcoholism  has  pro- 
voked (heart  and  kidney  diseases)  or  by  suicide. 

Pathological  Anatomy. 

The  chronic  alcoholist  often  exhibits  h^-perostosis  of  the 
cranium,  but  sometimes  also  attenuation  of  the  cranial  bones, 
external  and  internal  pachymeningitis,  very  often  hemorrhages 
into  the  membranes,  osteomata  of  the  dura  and  pia,  very  large 
Pacchionian  bodies,  changes  in  the  walls  of  the  arteries  of  the 
brain  (hyaline  fibroid  degeneration),  h}'pertrophy  of  the 
neuroglia,  degeneration  of  the  ganglion  cells — all  in  all,  there- 
fore, a  finding  which  is  also  observed  in  many  other  organic 
mental  diseases.  One  often  finds  degenerative  neuritis  in  the 
peripheral  nerves. 

The  organs  of  the  body  show  the  well-known  changes  of 
chronic  alcoholism,  especially  atheroma  of  the  vascular  system, 
dilatation  of  the  heart,  fatty  liver  and  cirrhosis  of  the  liver, 
kidney  changes,  chronic  catarrh  of  the  gastro-enteric  tract. 

The  treatment,  as  a  first  consideration,  must  regard  prophy- 
laxis, which  must  be  attained,  not  by  punishment  and  the 
courts,  but  by  good  example,  instruction,  and  a  general  better- 
ment of  the  hygienic  conditions,  especially  in  the  nutrition  of 
the  common  people.  Asylums  for  drunkards  are  an  aid  :  plac- 
ing the  alcoholist  imder  guardianship  will  be  sufficient  in  many 
cases  to  arrest  the  drunkard  in  his  course.  The  treatment  by 
medicines  has  alreadv  been  mentioned. 


The  Intoxication  Psychoses:  Morphine.  245 


(b)   Morphinism.! 

Bertrand  first  used  morphine  injections  in  Germany  in 
1856 ;  the  first  communications  on  the  aljuse  of  morphine  date 
from  the  year  1864.  Since  then  morphinism  has  had  a  fright- 
ful and  devastating  career. 

The  morphinist  is  a  man  of  a  double  personality:  After  ^ 
the  injection,  he  is  in  good  humor,  conciliating,  capable  of  labor; 
after  the  cessation  of  its  action  he  is  restless,  repulsive,  unable 
to  concentrate  himself,  dull  and  apprehensive.  A  new  injec- 
tion reanimates  him.  The  longer  the  morphinism  continues, 
the  shorter  become  the  intervals  between  the  injections  and  the 
shorter  the  euphoric  stage. 

The  most  prominent  pathological  mental  symptom  which  is 
brought  forth  by  the  abuse  of  morphine,  is  the  perversion  of  the 
moral  feelings,  as  has  been  described  in  depicting  the  chronic 
alcoholist.  The  morphinist  is  a  fiend.  Faith  and  belief  and 
honor  have  become  subordinate  in  his  consideration.  Loss  of 
intelligence  and  energy  follow  in  a  corresponding  manner.  His 
memory  generally  remains  good.  The  alcoholist  is  distin- 
guised  from  the  morphinist  in  that  the  former  easily  transfers 
his  ideas  to  the  motor  sphere  which  is  characteristic.  This  does 
not  take  place  with  the  morphinist  (Kraepelin). 

The  ideas  of  detraction  which  accompany  the  later  stages  of 
morphinism  in  most  cases  develop  to  a  true  delusion  of  atten- 
tion, and  may  rise  to  a  delusion  of  persecution  under  the  type 
of  paranoia  hallucinatorium.  Hallucinatory  states  of  excite- 
ment may  appear  transitorily  before  the  development  of  this 
chronic  condition. 

The  physical  symptoms  of  chronic  morphinism  manifest 
themselves,  above  all,  in  general  emaciation,  insomnia,  obstinate 
intestinal  obstruction,  trembling  of  the  tongue  and  hands,  weak- 
ness and  ataxia  of  the  arms  and  legs,  contracted  pupils  with 
conjunctivEe  generally  reddened  (the  pupils  are  spasmodically 
contracted,  Grafe).  Accompanying  these  is  loss  of  appetite,  the 
tongue  feels  rough  and  dry,  the  teeth  are  carious  and  fall  out, 
the" skin  is  sallow,  yellowish,  brittle,  on  it  there  are  scars,  ab- 


1  Erlenmeyer,  1887.     Third  edition. 


246  Special  Psychiatry. 


scesses,  indurations  in  consequence  of  the  injections,  sometimes 
also  blue  flecks  as  precipitates  of  small  pieces  of  metal  from  the 
canula  of  the  s3Tinge.  Moreover,  morphinists  complain  of  see- 
ing sparks,  roaring  in  the  ears,  abnormal  feelings  of  taste  and 
smell,  and  paresthesias.  Pollutions  and  erections  are  wanting, 
as  well  as  sexual  desire.  In  women  there  is  often  amenorrhea. 
Some  morphinists,  left  to  themselves,  die  from  cachexia,  others 
conunit  suicide  like  the  alcoholist. 

Etiology.  According  to  Pouchet,  40  per  cent,  of  all  the 
morphinists  are  physicians,  and  the  wives  of  ph3'sicians  also 
constitute  a  consideral^le  percentage.  Besides  j)hysicians,  drug- 
gists often  become  morphinists.  j\Iorphinism,  as  a  rule,  affects 
those  hereditarily  tainted,  who  have  less  energy  successfully  to 
opjDose  the  continued  use  of  the  drug.  The  misuse  of  morphine 
is  called  forth :  1,  by  continued  physical  pains ;  2,  by  insomnia ; 
3,  by  general  ill-feeling,  sorrow,  care;  4,  by  bad  example,  which 
is  especially  true  of  physicians'  wives.  The  pleasural^le  sen- 
sation which  the  injection  produces,  the  cessation  of  unrest  and 
anxiet}^  following,  urges  to  the  second  injection  when  the  effect 
of  the  first  has  worn  off,  and  thus  necessitates  an  increase  of  the 
dose.  Xew-born  children  from  morphinistic  mothers  sometimes 
show  symptoms  of  abstinence  with  collapse. 

The  largest  daih'  dose  of  morphine  which  has  been  observed 
in  morphinists  amounted  to  14  grams  (Jaquet). 

In  regard  to  the  diagnosis  of  an  existing  morphinism,  if 
denied  by  the  patient,  it  can  be  verified  by  the  appearance  of  the 
skin,  which  is  of  the  utmost  importance,  and  the  presence  of  the 
above-described  changes  conditioned  by  the  injections;  further, 
by  the  detection  of  morphine  in  the  urine.  Observation  shows 
also  in  the  continued  use  of  morphine  a  striking  change  of  the 
disposition,  which  is  euphoric  or  excited  when  the  patient  is 
under  the  influence  of  the  drug,  irritable  and  irascible  when 
hunger  for  the  drug  sets  in. 

The  treatment  of  morphinism  has,  for. its  prime  object,  the 
breaking  up  of  the  habit.  The  morphine  syringe  should  not  be 
trusted  to  any  patient,  not  even  to  the  attendant.  With  the 
high  percentage  of  morphinistic  physicians,  the  effect  of  this 
prophylaxis  will  always  be  limited. 

The  weaning  of  the  morphinist  may  be  effected  by  sudden. 


The  Intoxication  Psychoses:  Morphine.  247 


rapid  or  slow  withdrawal.  Which  method  is  best  in  a  given  case 
depends,  firstly,  on  the  usual  dose;  secondly,  on  the  condition 
of  the  strength  of  the  patient;  and  thirdly,  on  the  cause  which 
has  occasioned  the  morphinism.  If  violent  pains  still  continue, 
as,  e.g.,  in  carcinoma  or  tabes,  a  sudden  or  rapid  withdrawal  is 
not  possible  before  one  has  gradually  substituted  some  other 
anodyne  for  the  alleviation  of  the  pain. 

The  withdrawal  is  best  and  safest  in  an  institution. 
Morphinists  understand  so  well  how  to  deceive  physicians  and 
attendants  that  only  in  the  secure  conditions  of  a  closed  asylum, 
but  sometimes  not  even  there,  is  it  possible  to  deprive  the  patient 
of  his  morphine. 

During  the  treatment  by  withdrawal,  in  a  majority  of  cases 
greater  or  less  phenomena  of  abstinence  appear,  which  rest,  ac- 
cording to  Marme,  on  the  toxic  action  of  oxide  of  morphine 
formed  in  the  body  by  the  chronic  misuse  of  morphine  (a  product 
of  morphine,  not  excreted,  which  is  soluble  with  difficulty),  and 
this  is  not  inhibited  by  the  addition  of  new  morphine.  Other 
phenomena  of  abstinence  are  founded  on  a  hypersecretion  of 
hydrochloric  acid  in  the  stomach  after  the  withdrawal  of  mor- 
phine, which  may  be  shown  by  the  aid  of  the  stomach  tube 
(hence  pumping  out  the  stomach  and  administering  alkalies  is 
indicated). 

The  symptoms  of  abstinence  consist  of  vomiting,  yawning, 
sneezing,  profuse  perspiration,  twitching  of  single  muscles,  pre- 
cordial anxiety.  The  pupils  become  dilated,  quite  often 
dysarthric  disturbances  of  the  speech  develop,  also  violent  dry 
coughing,  changeable  pulse,  and  generally  subnormal  tempera- 
ture. The  patient  is  anxious,  excited,  wishes  to  die,  and  some- 
times attempts  suicide.  At  times  there  are  states  Avith  hallu- 
cinations and  delusions  as  in  alcoholic  delirium  tremens. 

Erections  and  pollutions  appear  in  men  during  the  period 
of  abstinence,  and  in  women  an  inclination  to  sexual  intercourse.. 

If  symptoms  of  collapse  appear,  subcutaneous  injections  of 
caffeino-natrium  salicylicum  are  recommended,  0.2  to  0.4,  also 
infusions  of  saline  solutions;  sometimes  an  injection  of  from 
0.03  to  0.05  of  morphine  cannot  be  avoided. 

The  inclination  to  suicide  should  be  especially  guarded 
against. 


248  Special  Psychiatry. 


If  the  morphine  is  successfully  withdrawn,  the  patient  will 
need  long,  careful  watching  before  he  can  be  considered  cured. 

Insomnia,  physical  pains,  and  unfavorable  social  surround- 
ings condition  the  recurrence  to  morphine  in  the  majority  of 
cases,  so  that  the  percentage  of  morphinists  who  may  be  regarded 
cured  must  be  considered  small.  One  often  finds  morphinism 
connected  with  alcoholism  and  cocainism. 

(c)   Cocainism.i 

Cocaine  was  first  emplo3^ed  by  Koller  in  1884  as  a  local  an- 
esthetic in  ophthalmology.  The  abuse  of  cocaine  proceeded 
from  its  use  as  a  local  anesthetic  for  pain  (cocainizing  the  gums, 
the  nose,  its  use  in  vaginismus),  then  as  a  consequence  of  mor- 
phinism. The  cocaine  syringe  was  heralded  at  first  as  an  antag- 
onist to  the  morphine  syringe.  The  symptoms  of  chronic  co- 
cainism are  general  exhaustion,  decrease  of  the  body  weight,  dis- 
gust with  and  incapability  of  mental  labor,  diminution  of  the 
intelligence,  forgetfulness,  insomnia,  acceleration  of  the  activity 
of  the  heart  with  small  and  filiform  pulse,  sometimes  spasms  in 
single  muscles, 

Occasionally  a  mental  disease  develops  on  this  basis,  which 
runs  under  the  type  of  delirium  hallucinatorium  with  many 
sense  deceptions,  especially  in  the  visual  tract.  A  feeling  of  for- 
eign bodies  under  the  skin  is  frequently  observed,  which  continu- 
ally change  their  location,  now  in  the  form  of  little  balls,  now  of 
small  kernels,  fine  powder  or  the  finest  dust  (Magnan's  S3'mp- 
tom).  Sometimes  there  arises  on  the  foundation  of  chronic 
cocainism  the  type  of  a  paranoia  hallucinatoria  Avith  systematized 
ideas  of  persecution,  hallucinations  of  vision  and  audition. 

The  symptoms  of  cocainism  are  more  obstinate  and  severe 
than  those  of  morphinism.  Cocainists,  as  a  rule,  are  not  able 
to  pursue  their  occupation  as  long  as  morphinists.  Morpliine 
and  cocaine,  used  together,  are  most  deleterious. 

The  treatment  is  essentially  the  same  as  for  morphinism. 
Xoteworthy  phenomena  of  abstinence  do  not  appear  as  a  rule  in 
cocainism. 


^  Mannheiiru    Neurologisches  Centralblatt,  1891. 


The  Intoxication  Psychoses:  Drugs.  249 

Appendix. 

Of  the  other  chronic  intoxications  with  organic  poisons, 
chloralisin  shoukl  be  mentioned,  which  shows,  besides  consider- 
able emaciation  and  diarrhea,  decided  cutaneous  eruption 
(urticaria,  erythema,  papulous  exanthemata,  petechia)  ;  Chloro- 
formism;  Etheromania;  Ahsinthism,  whose  symptoms  Magnan 
gives  as  attacks  of  dizziness,  hallucinatory  deliria,  amnesia ; 
chronic  use  of  opium;  Cannahism,  especially  as  practiced  in 
Egypt;  Nicotinism.  Further,  mention  should  be  made  here  of 
the  chronic  intoxications  with  preparations  of  bromide,  sulfonal, 
trional,  stramonium  (the  chronic  intoxication  may  arise  from 
the  constant  use  of  stramonium  smoke  in  asthma;  it  calls  forth 
auditory  hallucinations  and  the  delusion  of  attention  with  pres- 
sure on  the  head,  feeling  of  pressure  in  the  ear  and  in  the  foot 
articulations),  with  atropine,  hyoscyamus,  salicylates  (with  pro- 
fuse sweats,  roarings  in  the  ears,  difficulty  of  hearing,  mydriasis, 
strabismus),  antipyrin,  and  paraldehyde. 

All  these  poisons  may  bring  on  acute  mental  disturbances 
which  disappear  quickly,  but  they  may  also  generate  subacute 
ones,  generally  in  the  form  of  delirium  hallucinatorium  or  of 
acute  hallucinatory  paranoia.  Chronic  absinthism  often  leads 
to  dementia,  as  does  also  cannabism.  Chronic  intoxications  with 
sulfonal,  trional,  and  with  bromide  may  bring  on  states  of  mental 
weakness,  considerable  loss  of  memory  with  ataxia,  pareses,  and 
loss  of  the  patellar  reflexes,  so  that  the  external  type  is  that  of 
paresis.  The  anamnesia  and  the  further  course,  which  shows 
the  gradual  disappearance  of  the  symptoms  with  the  removal 
of  the  drug,  assure  the  diagnosis. 

4.  Psychoses  which  are  Brought  on  by  Inorganic  Poisons. 

Acute  cafbonic  acid  gas  psychoses  sometimes  shows  the  type 
of  acute  dementia.  If  there  are  paralyses  present  in  such  psy- 
choses, these  point  to  localized  foci  of  softening  in  the  brain, 
which  are  conditioned  by  the  intoxication. 

Chronic  carbonic  acid  gas  intoxication,  which  appears  with 
the  symptoms  of  hallucinatory  paranoia,  or  also  a  pseudo-paresis, 
has  been  described  by  Moreau  as  it  presents  itself  in  bakers  and 
cooks;  psychoses  have  also  been  observed  from  Gaz  pauire  (by 


250  Special  Psycliiatry. 


passing  air  over  heated  anthracite  there  is  a  mixture  of  nitrogen, 
carbonic  acid  gas,  carbonic  acid,  and  a  small  quantity  of  carbo- 
hydrogen). 

Carbonic  disuli^hide  psychoses^  may  appear  as  a  state  of 
depression  which  may  rise  to  stupor,  or  under  the  type  of 
delirium  liallucinatorium.  Generally  there  arise  states  of  men- 
tal weakness,  and  with  these  symptoms  of  paralysis  or  ataxia 
are  often  associated. 

Iodoform  may  generate  an  acute  psychosis  under  the  type  of 
delirium  hallucinatoriiim  with  anxious  unrest,  or  of  great  con- 
fusion, or  it  may  also  run  under  the  t3'pe  of  melancholia.  One 
should  always  consider  carefully  in  such  cases  whether  the  dis- 
ease which  necessitated  the  use  of  iodoform,  or  the  shock  which 
followed  the  operation,  forms  the  etiological  momentum. 

Chronic  saturnism  may  generate: 

(a)  A  psychosis  which  runs  acutely  under  the  type  of  de- 
lirium liallucinatorium. 

(&)  Epileptic  seizures  with  their  peculiar  pathological 
psychic  symptoms. 

(c)  Diminution  of  the  intelligence  and  the  memory,  by 
which  the  clinical' type  of  paresis  may  be  evolved  in  connection 
with  the  paralytic  states  peculiar  to  lead-poisoning.  One  should 
observe  diagnostically  in  this  connection  that  the  dementia  in 
saturnine  paralysis  is  never  of  so  high  a  degree  as  in  paresis; 
further,  that  electric  examination  in  lead-poisoning  shows 
changes  which  are  absent  in  paresis;  that  examination  with  the 
ophthalmoscope  shows  neuritis  and  neuroretinitis,  retinal  apo- 
plexies, and  perivascular  changes  (Hirschberg),  which  are  for- 
eign to  the  paresis  in  this  symptom-complex. 

Saturnism  may  also  beget  uremic  psychoses  through  con- 
tracted kidneys. 

Chronic  mercurial  intoxication  often  introduces  states  of 
considerable  fearfulness,  easy  irritation  by  external  impressions, 
anxiety  and  insomnia  (erethismus  mercurialis) .  In  rare  cases 
a  psychosis  which  may  lead  to  mental  weakness  with  depressive 
symptoms  develops  from  this  condition  when  the  predisposition 
is  present. 

^Koster.     Neurologisches    Centralblatt,    1898,     Laudenbeimer,    the 


Tlio.  Organic  Psychoses:  Paresis.  251 

V.  THE  ORGANIC  PSYCHOSES. 

1.  Diffuse  Diseases  of  the  Brain  Cortex. 

(a)   Progressive   Paralysis  of  the   Insane. "^      (Paralytic   Dementia, 
Paresis,  Softening  of  the  Brain). 

Although  cases  were  reported  in  1672  by  Willis  and  in 
1798  by  Haslam  which  may  belong  to  paresis,  yet  it  was  Bayle 
Avho  inaugurated  the  history  of  the  progressive  paralysis  of  the 
insane  by  his  inaugural  dissertation  in  the  year  1822.  He 
called  the  disease  chronic  meningitis,  and  thought  that  the  men- 
tal as  well  as  the  somatic  pathological  symptoms  developed  from 
this  as  a  pathological  unit. 

At  a  later  time  the  strife  was  again  taken  up  as  to  whether 
the  psychic  disturbances  and  the  somatic  changes  really  belonged 
to  one  disease,  or  were  rather  a  symptom-complex.  The  Con- 
gress of  Physicians  for  the  Insane,  held  at  Paris  in  1867,  con- 
firmed the  unity  of  the  pathological  symptoms  and  considered 
paresis  as  a  special  clinical  entity. 

Although  at  the  time  there  was  no  dissent  concerning  this 
fact,  later  researches  strove  to  separate  forms  which  were  con- 
spicuous anatomically  and  clinically,  from  the  great  number 
of  the  cases  which  were  regarded  as  paresis. 

In  by  far  the  great  majority  of  cases  the  pathological  type 
develops  in  the  following  manner: 

1.  The  demented  form  of  paresis. 

The  first  stage.  This  consists  preferably  in  the  symptoms 
of  the  pathological  change  of  the  psyche,  or  in  those  of  the  body, 
or,  finally,  in  the  contemporaneous  development  of  both  mental 
and  physical  abnormalities. 

(a)  The  patient  l)ecomes  depressed,  irritable,  violent,  brutal 
without  sufficient  cause,  laying  violent  hands  on  himself.  With 
this,  his  neglect  of  certain  social  rules  is  conspicuous ;  he  comes 
into  a  room  with  his  hat  on  his  head,  he  appears  in  society  with 
disordered  dress,  his  face  and  hands  are  dirty,  he  treats  women 


^Mendel.     Piofri'essive  Paralyse.     Monographic,  1880.     Binswanger, 
Deutsche  Klinik,  1901. 


252  Special  Psijchiatry. 


indecently  and  without  respect  both  in  his  words  and  gestures, 
where  before  he  was  reserved;  contrary  to  his  former  habits,  he 
frequents  saloons  and  low  resorts.  In  many  cases,  even  in  this 
stage,  an  inclination  to  immoral  actions  develops  whose  execution 
brings  the  patient  into  contact  with  the  criminal  law  (offenses 
against  decency,  exposure,  theft,  and  the  like). 

Meanwhile  there  are  depressions,  anxious  states,  and  con- 
siderable feeling  of  illness.  Sleep  is  diminished  usually  both 
as  to  duration  and  soundness.  In  other  cases,  on  the  contrary, 
there  is  morbid  sleepiness,  which  sometimes  comes  on  in  the 
form  of  attacks  at  unseasonable  times  and  places  (narcolepsy). 

These  changes  are  often  observed  on  intimate  acquaintance 
with  the  patient;  sometimes,  eA'en  then,  they  are  not  recognized 
as  pathological,  but  attributed  to  other  circumstances.  The 
patient  often  works  at  his  occupation  as  before,  that  is,  he  per- 
forms his  ordinary  daily  task  in  the  prescribed  way.  But  if  un- 
usual obstacles  are  encountered,  he  soon  shows  his  defective  intel- 
ligence, while,  on  the  other  hand,  energy  for  new  enterprises  is 
wanting.  If  he  attempts  them  notwithstanding,  he  generally 
fails  because  he  lacks  the  mental  power. 

A  consciousness  of  disease  appears  transitorily,  especially 
if  the  patient  notices  the  diminution  of  his  memory  or  if  others 
point  out  to  him  his  peculiar  condition.  He  "has  a  presenti- 
ment of  the  on-coming  softening  of  the  brain"  and  sometimes 
commits  suicide  when  he  recognizes  it. 

Somatic  changes  are  not  present  as  a  rule,  or  are  so  incon- 
spicuous that  the  family  physician  diagnoses  "neurasthenia," 
and  even  the  psychiatrist  who  may  be  called,  though  he  recog- 
nizes the  danger,  cannot  make  a  positive  diagnosis,  because 
of  absence  of  all  objective  symptoms  of  the  peripheral  nervous 
system. 

(&)  The  disease  begins  with  reflex  rigidity  of  the  pupils, 
myosis  or  mydriasis  in  one  or  both  eyes,  alteration  of  the  tendon 
reflexes  (too  weak,  absent,  sluggish  reaction,  while  the  return  is 
not  lightning-like,  but  lax,  slow,  or  too  strong,  patellar  or  foot 
clonus),  analgesia,  especialh'  in  the  leg,  exaggeration  or  dimi- 
nution and  extinguishment  of  the  sexual  reflexes,  easy  fa- 
tigue of  the  legs,  intermittent  limping.     There  is  now  hesitation 


The  Organic  Psychoses:  Paresis.  253 


in  the  speech,  especially  in  excitement,  sometimes  obvious  para- 
lytic disturbances  of  the  speech. 

Notwithstanding,  the  patient  manages  his  business  without 
trouble,  but  shows  his  inefficiency  when  he  confronts  new  prob- 
lems. Certain  hypochondric  complaints,  some  irritability, 
disturbances  of  the  sleep  are  seldom  lacking.  The  diagnosis  here 
wavers  between  tabes  and  paresis,  especially  if  the  patellar  re- 
flexes appear  to  indicate  the  first  and  the  mental  weakness  is  not 
conspicuous. 

2.  The  symptoms  described  under  (a)  and  (6)  develop  con- 
temporaneously; the  diagnosis  may  be  made  with  confidence 
even  in  this  stage.  On  taking  up  the  anamnesia  it  appears  gen- 
erally that  syphilis  was  present  about  ten  to  fifteen  years  before 
the  beginning  of  the  present  disease;  that  other  severe  diseases 
and  those  of  the  nervous  system  have  not  in  the  majority  of 
cases  preceded  the  present  difficulty. 

Second  stage.  The  mental  weakness  is  clearly  defined,  the 
memory  fails  considerably,  the  patient  shows  indifference  to 
those  about  him  and  as  to  his  business,  his  speech  changes  more 
and  more,  the  paralytic  disturbances  of  speech  persist.  There 
are  now  paralytic  attacks,  sometimes  in  the  mildest  form,  as  diz- 
ziness or  temporary  loss  of  consciousness,  but  always  with  the 
evident  effect  of  further  weakening  the  mental  power.  The 
somatic  s^miptoms  are  partially  unchanged,  in  part  they  become 
stronger;  in  particular,  the  weakness  or  ataxia  of  the  extremities 
increases.  The  patient,  on  account  of  his  intellectual  weakness, 
is  incapable  of  mental  labor,  and  also  unfit  for  bodily  exertion 
from  the  paresis  or  ataxia  of  his  extremities. 

Third  stage.  The  mental  weakness  sinks  to  dementia, 
memory  has  almost  vanished,  the  patient  can  no  longer  answer 
the  simplest  questions,  becomes  wholly  indifferent.  The  muscu- 
lar paralysis  demands  the  help  of  others  in  carrying  out  the 
simplest  movements,  urine  and  feces  pass  involuntarily.  Para- 
lytic attacks  make  the  helplessness  of  the  patient  still  worse. 
He  dies  in  such  an  attack,  or  of  an  aspiration  pneumonia,  or  of 
an  intercurrent  disease. 

During  the  course  of  this  demented  form  there  appear  occa- 
sionally depressive  or  maniacal  delusions,  which  may  exist  for  a 
greater  or  less  time  alongside  the  other  symptoms.     However, 


254  Special  Psychiatry. 


the  pathological  type  is  not  influenced  by  them;  these  ideas  are 
generally  only  produced  when  the  patient  is  directly  questioned 
concerning  them. 

2.  The  classical  or  typical  form  of  paresis. 

The  first  stage  may  show  all  the  above-described  varieties; 
often  it  is  imperfectly  developed  and  there  exists  only  a  certain 
psychic  irritability  with  definite  hypochondric  impressions. 
As  the  second  stage,  there  appears  a  state  of  hypochondric 
or  melancholic  depression,  which,  according  to  the  degree  of 
its  development,  may  waver  between  the  mild  form  of  hypomel- 
ancholia  or  hypochondria  to  the  highest  grade  of  stupor,  and  the 
delusions  may  be  cpiite  similar  in  content  to  the  typical  melan- 
cholia just  described.  Characteristic,  however,  are  the  symptoms 
of  mental  weakness,  which  are  connected  with  those  delusions, 
also  the  above-described  somatic  symptoms,  the  change  of  the 
tendon  and  visceral  reflexes,  as  well  as  the  disturbances  of  speech 
which  have  already  revealed  themselves  very  plainly. 

The  third  stage — maniacal  exaltation — generally  develops 
gradually  from  the  second;  it  is  distingiiished  by  the  so-called 
efflorescent  megalomania,  whose  growth  knows  no  limits.  Its 
further  development,  together  with  the  motor  excitation,  leads 
to  paretic  raving.  Paralytic  attacks  then  quite  often  interrupt 
the  agitation  and  bring  the  patient,  with  increasing  dementia 
and  paralysis,  into  the  fourth  stage,  the  stage  of  dementia.  It 
is  the  same  as  the  above-described  third  stage  of  the  demented 
form,  and  entails  only  the  nonsensical  megalomaniacal  ideas  of 
the  earlier  stages;  but  even  these  are  brought  forth  without  ex- 
citement as  something  indifferent  and  with  halting  paralytic 
speech. 

3.  That  course  is  described  as  the  agitated  form  of  paresis 
in  which  the  melancholic  and  h}'pochondric  stage  of  typical 
paresis  is  absent  and  the  disease,  after  the  first  stage,  passes  di- 
rectly into  the  third.  Sometimes  the  symptomatic  t}^e  of  acute 
delirium  appears  in  an  esjDecialh'  violent  course,  complicated 
with  somatic  diseases. 

4.  In  the  depressive  fonn,  a  maniacal  stage  is  developed, 
the  h}^ochondriaco-melancholic  delusions  rise  to  excessive 
height,  quite  often  to  micromania. 

5.  If  interchanging  depressive  and   exalted   stages   appear, 


The  Organic  Psijchoses:  Paresis.  255 


the  paresis  iiiay  simulate  a  circular  psychosis  (the  circular  form 
of  paresis).  Increasing  mental  weakness  and  the  somatic  symp- 
toms confirm  the  diagnosis. 

G.  Where  the  psychic  symptoms  of  paresis  range  themselves 
for  a  long  time  alongside  an  existing  tabes,  even  a  decennium  or 
longer,  one  speaks  of  an  ascending  paresis. 

Not  only  the  tabes,  but  also  the  associated  paresis,  is  con- 
spicuous by  a  long  course.  From  these  cases  are  to  be  distin- 
guished those  in  which  tabetic  symptoms  appear  with  pathologi- 
cal phenomena  or  where  the  tabetic  symptoms  quickly  follow  the 
])aretic.  In  these  last  cases  we  do  not  have  pathologico-ana- 
tomically  a  pure  posterior  column  sclerosis  ( tab o- paresis). 

.Special  Symptomatology. 

1.  Hallucinations,  as  a  rule,  first  appear  in  paretics  in  the 
later  stages,  exceptionally  hallucinations  of  vision  appear  in 
the  first  stage;  "Snow  is  falling  before  my  eyes,'^  "the  devil  is 
in  sight."  Auditory  hallucinations  first  appear  in  the  later 
stages  generally,  in  the  state  of  raving  or  frequently  in  the  de- 
pressive forms;  hallucinations  of  smell  and  taste  are  quite  fre 
quent  in  the  raving  of  paretics,  while  hallucinations  of  the 
coenesthetic  sense  distinguish  the  hypochondric  stage  of 
paresis. 

2.  Mental  iveakness  is  the  finger  mark  which  is  seen  from 
the  beginning  to  the  end  of  the  manifold  picture  of  paresis.  It 
is  sometimes  striking  how  the  paretic,  still  occupied  in  his  busi- 
ness and  considered  by  his  associates  as  simply  nervous,  wholly 
fails  in  simple  calculations,  as  13  times  13,  or  in  computing  the 
interest  of  a  given  sum  at  41/2  per  cent,  for  one  year.  Either 
he  cannot  solve  the  problem  or  his  solutions  are  faulty. 

He  first  loses  the  highest  intellectual  conceptions,  those 
which  he  acquired  last,  while  external  forms  remain  longest  (in 
physicians,  e.g.,  the  writing  of  prescriptions).  The  delusions 
of  the  paretic  are  distinguished,  both  after  the  depressive  and 
maniacal  states,  by  their  nonsensical  exaggerations  and  arbitrary 
excesses.  Ideas  of  persecution  and  megalomania  may  combine 
in  the  same  manner  as  in  paranoia. 

The  hypochondric  impressions  which  are  at  first  present 
change,   during  the  further   course,  to   euphoria,   even  in  the 


256  Special  Psychiatry. 


demented  form  of  paresis.  Of  the  intellectual  feelings,  the 
ethical  and  esthetic  suffer  regularl}'  even  in  an  earlier  stage. 

In  this  respect  the  erotic  phenomena  are  to  be  mentioned, 
which  cause  the  patients,  in  the  absence  of  ethical  feelings,  to 
bring  public  women  into  their  families  or  to  abandon  themselves 
to  shameless  excesses. 

Although  the  memorj-  in  the  earlier  stages  of  paresis  often 
shows  no  appreciable  defect,  it  is  essentiaily  weakened  in  the 
later  stages,  the  power  of  attention  vanishes,  and  finalty  the 
paretic  finds  himself  in  a  situation  in  which,  separated  from 
his  past,  and  incapable  of  acquiring  anything  new,  he  lives  en- 
tirely in  the  gratification  of  sensual  desires. 

Syllable-stumbling  is  characteristic  of  paresis.  While  sin- 
gle words  and  syllables  are  plainly  pronounced,  when  separated 
it  is  not  possible  for  the  patient  to  arrange  them  in  euphonious 
order  in  a  phrase,  especially  if  it  be  a  long  one.  The  vowels  or 
all  the  syllables  are  mutilated,  single  vowels  are  repeated  at  un- 
suitable jolaces,  others  are  omitted.  This  is  very  evident  if  long 
words  are  given  the  patient  to  pronounce:  instead  of  "artillery^' 
we  have  "ratrillery,"  instead  of  "Constantinopolitan"  "Costa- 
pinopalic,"  instead  of  "San  Francisco,"  "Fran  Sanfis — Fran 
Sanfrisco." 

These  disturbances  of  speech  sometimes  appear  more  clearly 
in  reading  or  reciting  than  in  repeating,  especially  if  the  patient 
has  already  practiced  the  last.  Often,  hesitation  of  speech  has 
been  observed  in  paretics,  even  before  the  appearance  of  the 
s3-llable-stumbling,  especially  when  it  has  been  difficult  to  pro- 
nounce single  definite  consonants  at  the  beginning  of  the  word ; 
speech  is  therefore  hesitating,  retarded. 

The  disturbances  of  speech  as  mentioned  appear  at  a  very 
early  stage  in  the  majority  of  cases  of  dementia  parah'tica.  If 
they  do  not  make  the  diagnosis  of  paresis  absolutely  sure,  since 
they  occasionally  appear  in  other  circumstances  (e.g.,  in  alco- 
holism under  the  influence  of  acute  intoxication,  with  hyoscin, 
duboisin  in  psychic  patients),  nevertheless  the  utterance  of 
Esquirol,  "disturbance  of  speech  is  a  fatal  symptom,"  is  correct 
with  very  inconsiderable  limitations.  Disorders  of  speech  are 
not  always  uniformly  present;  sometimes  they  disappear  in  re- 
pose, while  they  are  more  accentuated  during  excitement. 


The  Organic  Psychoses:  Paresis.  257 

Syllable-stammering  is  not  the  only  form  of  speech-dis- 
turbance to  be  noted,  for  in  the  later  stages  of  tlie  disease  occur 
weakness  of  memory  and  troubles  of  the  articulation  (dysar- 
thria), which  complicate  the  speech  still  further. 

The  patient  begins  to  speak,  does  not  find  the  right  expres- 
sion for  what  he  wishes  to  say,  and  breaks  off  for  that  reason; 
begins  anew  the  sentence  which  has  not  yet  ended,  now  forgets 
what  he  wished  to  say,  looks  around  questioning,  and  closes  the 
sentence  with  a  phrase  which  has  no  connection  with  what  was 
first  said.  He  often  forgets  the  last  syllable  of  the  words  he 
is  speaking. 

In  advanced  cases,  the  muscular  fibers  of  the  tongue,  lips, 
face,  sometimes  of  the  lower  jaw,  finally  begin  to  tremljle  when 
the  patient  opens  his  mouth  to  speak;  these  tremblings  are 
especially  conspicuous  in  the  levator  labii  superioris,  the  zygo- 
matic muscles,  the  orbicularis  palpebrarum,  and  are  so  strong 
sometimes  that  the  whole  countenance  seems  convulsed  with 
spasmodic  twitchings. 

After  some  seconds,  sometimes  after  a  minute  of  effort,  the 
first  syllable  is  uttered. 

The  tone  of  the  voice  is  often  changed  with  this :  rough, 
nasal,  conspicuously  deep. 

The  writings  of  the  paretic  exhibit  mental  weakness  and 
delusions  in  their  diverse  form.  The  maniacal  excitement  is 
shown  in  the  manifold  underscoring  of  the  words,  the  exclama- 
tion point,  the  ordering  of  letters  forwarded  by  "wire,"  by 
"reed,  post,"  "per  express." 

Literal  and  verbal  paragraphia  correspond  to  syllable- 
stumbling. 

The  script  itself  may  be  atactic  (excessively  elaborated  let- 
ters besides  small,  zigzag-shaped  ones  with  thick  ground  lines)  or 
trembling. 

The  reading  corresponds  with  the  speaking.  Sometimes 
paretics  read  something  which  is  not  in  the  book  and  which  has 
no  connection  with  it.  Sometimes  dyslexia  is  observed :  after 
a  few  lines  the  patient  cannot  read  further,  because  it  is  difficult, 
because  he  feels  badly. 


17 


258  Special  Psychiatry. 


Somatic  Symptoms. 

1.  Motility.  At  an  early  stage  appear,  with  paresis,  spas- 
modic symptoms  in  the  form  of  gnashing  of  the  teeth,  chewing 
motions,  spasms  of  single  muscles,  even  like  writers'  cramp. 
The  symptoms  of  paralysis  first  show  themselves  as  quick  twitch- 
ing in  the  facial  muscles,  in  those  of  the  tongue,  especially  in 
attempts  to  speak  or  to  protrude  the  tongue,  then  in  the  hands, 
also  in  the  musculature  of  all  the  rest  of  the  body,  often  as  fibril- 
lary twdtchings.  Choreic  movements  are  rare.  There  appear 
early  inequality  of  the  clefts  of  the  eyelids,  weakness  of  orbi- 
cularis palpebrarum,  difi'erence  of  the  pupils  (myosis  in  about  60 
to  70  per  cent,  of  all  cases,  mydriasis  more  rarely),  unequal  in- 
nervation of  the  faciales,  tongue  protruded  obliquely.  In  the 
further'  course  the  paresis  attacks  the  entire  musculature,  and 
finally  reaches  paralysis.  The  walk  of  the  paralytic,  which  is  a 
paretic  or  paretic-spastic  (with  exaggerated  tendon  reflexes)  or 
atactic  (with  diminished  or  absent  tendon  reflexes),  becomes 
finally  impossible.  Hemiplegias  and  monoplegias  also  appear  in 
connection  with  the  paralytic  attacks,  are  sometimes  produced  by 
paralyses  of  single  nerves  as  a  result  of  a  periplieral  neuritis 
(peroneus  paralysis).  Pareses  and  paralyses  of  the  hands, 
paresis  of  the  sphincters,  and  paralysis  of  all  the  flexor  muscles 
characterize  the  end  stadium. 

The  electrical  excitability  of  the  muscles  and  nerves  is  not 
changed  in  paresis.  If  there  is  a  change  in  the  electrical  reac- 
tion, complications  should  be  suspected. 

2.  Organs  of  sense  and  sensihiUty  of  the  shin.  Atrophy  of 
the  optic  nerve  is  present  in  about  12  per  cent.,  especially  in 
the  tabetic  form.  Constant  and  even  progressive  central 
scotoma  with  coloring  of  the  entrance  of  the  optic  nerve,  hemi- 
anopsia in  connection  with  paralytic 'attacks  are  sometimes  ob- 
served. Disturbances  of  audition  are  rarely  present,  more  fre- 
quent are  anosmia  and  ageusia,  also  in  the  earlier  stages.  N'eu- 
ralgiform  pains  (sciatica)  often  appear  in  the  first  stage,  more 
or  less  diffused,  anesthesias  and  analgesias  very  early,  especially 
of  the  lower  extremities.  Yet  one  should  be  careful  not  to  as- 
sume analgesia  from  the  patient's  declaration  that  he  "feels  no 
pain"  from  the  prick  of  a  needle;  the  maniacal  patient,  espe- 


The  Organic  Psychoses:  Paresis.  259 

ciall}',  denies  the  pain  in  order  to  prove  his  health  or  his  power 
of  resistance. 

3.  Reflexes.  The  condition  of  the  patellar  reflexes  has  al- 
ready heen  mentioned.  The  Achilles  tendon  reflex  and  that  of 
the  anconeus  are  often  found  diminished  or  absent  in  the  be- 
ginning of  the  paresis. 

The  skin  reflexes  are  often  exaggerated  in  the  first  stage, 
weak  in  the  later  stages.  Babinski's  reflex  is  often  found  on 
one  or  both  sides.  The  abolition  of  the  pupil  reflexes  for  light 
is  one  of  the  earliest  and  most  important  symptoms  of  the 
visceral  reflexes.^  Coincidentally  appear,  also,  the  paradoxical 
and  inverse  pupil  reactions. 

The  vesical  reflex,  as  a  rule,  suffers  early ;  in  the  later  stages 
its  paralysis,  with  paralysis  of  the  detrusor  uringe  and  sphincter 
vesicae,  leads  to  ischuria  paradoxa. 

The  sexual  reflex  is  often  normal  in  the  beginning  of  the 
disease,  sometimes  heightened  (pollutions),  and  later  habitually 
becomes  extinguished. 

4.  Vasomotor  and  tropliic  disturbances.  Diminution  or 
increase  of  the  saliva  and  perspiration  is  frequent.  Some  of 
the  phenomena  which  have  been  described  as  trophic  disturbances 
are  consequences  of  uncleanliness  in  connection  with  the  constant 
anesthesia  of  the  skin  (erythema,  furunculosis,  decubitus). 

On  the  other  hand,  insignificant  traumata  in  organs  pre- 
viously altered  by  trophic  disturbances  may  cause  wide-spread 
destruction  (decubitus  acutissimus  may  sometimes  arise  during 
a  night).  Fractures  of  the  ribs,  fractures  of  the  extremities, 
arthropathies,-  hematomata  belong  in  this  category. 

The  Aveight  of  the  body  is  apt  to  decrease  very  appreciably 
in  the  h3''pochondric  and  maniacal  stages  of  paresis,  but  often 
increases  considerably  in  a  certain  period  of  the  last  stage;  then 
it  again  diminishes  very  rapidly,  as  a  general  rule,  before  disso- 
lution, without  any  reason  being  found  either  in  diarrheas  or 
in  faulty  nutrition. 

5.  The  internal  organs  in  very  many  cases  of  paresis  show 
no   change,  syphilitic   affections   are   found   only   exceptionally. 


*  Moeli.     Archiv  fiir  Psychiatrie,  vol.  viii,  page  13-18. 
^  Westphal.     Charitg-Annalen.,  vol.  xx. 


260  Special  Psychiatry. 


The  pulse  is  usuall}^  regular;  in  the  later  stages  the  sphygmo- 
gram  shows  anacrotic  and  katacrotic  ascents  and  the  sign  of 
pulsus  tardus.  The  temperature  is  generally  normal,  except 
in  the  last  stage,  where  it  is  often  subnormal  and  falls  sometimes 
to  80°  F.  Elevation  of  the  temperature  always  points  to  com- 
plications. Peptonuria,  diminution  of  the  urea,  of  the  chlorides, 
and  of  phosphoric  acid  is  often  found. 

Menstruation  is  generally  undisturbed,  yet  the  menopause, 
as  a  rule,  appears  prematurely. 

6.  Paralytic  attacl's.  These  show  themselves  in  the  course 
of  paresis  in  all  stages,  often  even  in  the  first: 

(a)  As  apoplectiform. 

(h)   As  epile]3tiform. 

(c)  As  epileptoid. 

The  first  fluctuate  in  their  development  between  the  ap- 
p«?arance  of  a  quickly  passing  motor  or  sensory  aphasia,  a  transi- 
tory condition  of  weakness  in  the  hand  while  writing,  a  quickly 
disappearing  dizziness  which  may  also  accompany  the  symptoms 
noted  and  a  loss  of  consciousness,  lasting  for  hours  or  days,  with 
following  hemipareses  or  hemiplegias,  which  usually  pass  away 
in  a  few  hours  or  days. 

The  epileptiform  attacks  fluctuate  between  the  twitching 
of  single  extremities,  or  the  mildest  form  of  a  Jacksonian  epi- 
lepsy, to  the  typical  picture  of  a  classical  epileptic  seizure,  which 
may  pass  into  a  status  epilepticus. 

Finally,  the  epileptoid  attacks  show  clouding  or  total  loss 
of  self-consciousness,  with  complete  passivity  or  impulsive  run- 
ning around  without  aim  or  reason,  also  in  the  form  of  twilight 
states. 

Sometimes  a  state  of  delirium  hallucinatorium  is  connected 
with  the  paralytic  attack,  which  may  resemble  very  much  an 
alcoholic  delirium. 

The  paralytic  attacks  have  a  tendency  to  accelerate  the 
progress  of  the  disease  by  injuring  the  somatic  and  mental  fimc- 
tions.  Death  often  follows  in  the  apoplectic  attack  or  in  the 
epileptic  seizure. 

7.  A  cj'tological  examination  of  the  cerebro-spinal  fluid  has 
been  recommended  as  a  means  of  diagnosis  in  cases  of  paresis, 
and  especially  in  those  cases  where  the  diagnosis  of  paresis 


The  Organic  Psychoses:  Paresis.  261 


seemed  doubtful.  Brooks  and  Clark^  have  published  the  results 
of  their  investigations  and  their  manner  of  procedure,  which 
are  a  good  index  of  the  work  done  along  these  lines,  and  their 
results  are  briefly  as  follows: — 

"After  centrifuging  and  staining  the  spinal  fluid,  we  have 
counted  from  30  to  50  fields  in  each  case  and  have  looked  upon 
the  presence  of  one  or  more  lymphocytes  to  a  field  as  indicating 
a  lymphocytosis,  while  the  normal  fluids  have  usually  presented 
one  lymph »3yte  to  from  5  to  20  fields.  With  the  counting 
chamber  we  have  considered  anything  over  14  or  15  to  a  cubic 
millimeter  as  an  increase,  while  the  normal  fluids  presented  from 
1  to  4,  or  less,  to  the  cubic  millimeter. 

"We  have  made  satisfactory  examinations  of  fluid  in  29 
cases,  13  of  which  have  been  typical  paretics,  3  probable  paretics, 
and  thirteen  suffering  from  other  conditions,  from  which  paresis 
could  be  absolutely  excluded. 

"Of  the  13  typical  paretics  we  found  an  abnormal  increase 
in  the  number  of  lymphocytes  in  8,  or  practically  6IV2  per  cent. 
If  to  these  we  add  the  three  probable  paretics,  in  all  of  whom 
there  was  a  lymphocytosis,  the  result  is  68V4  per  cent,  increased. 
"Of  the  13  cases  other  than  paretics,  11,  or  practically  S-tVg 
per  cent.,  presented  a  normal  lymphocyte  count.  Of  the  other 
two,  one  gave  a  history  of  syphilis,  some  twenty  years  before, 
and  the  other  was  evidently  suffering  from  a  syphilitic  and  in- 
flammatory condition  of  the  meninges,  which  condition  was 
cured  by  treatment  with  potassium  iodide.  To  recapitulate: 
68V^  per  cent,  of  our  paretics  showed  an  abnormal  lymphocy- 
tosis, while  in  84-/3  per  cent,  of  the  cases  other  than  paresis 
the  lymphocytes  were  normal  in  number. 

"The  seralbumin  present  in  the  fluid  we  found  to  be  a  vari- 
able quantity,  and,  so  far  as  we  were  able  to  determine,  bore  no 
particular  relation  to  the  number  of  lymphocytes  present  or  to 
the  presence  or  absence  of  dementia  paralytica.  It  was  markedly 
increased,  in  two  cases  giving  evidence  of  meningeal  inflamma- 
tion (showing  polynuclear  leucocytes  in  the  fluid)  and  in  a  case 
of  dementia  paralytica  associated  with  tabes." 

Etiology.     Progressive  paralysis  is  a  disease  which  demands 


Medical  Record,  New  York,  June  30,  1906. 


262  Special  Psychiatry. 


its  -victims  with  increasing  frequency.  At  the  beginning  of  the 
last  century  scarcely  known,  patients  afflicted  with  this  disease 
now  fill  the  sanitariums,  a  large  percentage  fill  the  private  in- 
stitutions and  those  other  public  asylums  which  receive  their 
patients  from  the  populous  centers  of  the  state.  [The  frequency 
of  paresis  in  America  is  by  no  means  so  great  as  in  Germany. 
During  the  year  190-1,  out  of  5788  admissions  to  the  Xew  York 
State  hospitals,  164  were  paretics,  or  8  per  cent.  Since  1888, 
of  84,152  insane  admitted,  5697,  or  6.7  per  cent.,  w^re  afflicted 
with  paresis. — Ed.] 

Paresis  is  a  disease  of  civilized  life,  seldom  ever  appearing 
among  the  semi-civilized  or  uncivilized.  It  is  rarer  in  the 
country  than  in  the  cities,  it  affects  men  much  more  frequently 
than  women,  the  ration  of  inclination  being  4  to  1.^  Among 
men  the  so-called  better  classes  are  attacked  with  greater  fre- 
quency, while  among  women  it  is  of  the  poorer  population. 
With  men  the  age  of  greatest  incidence  is  from  thirtj^-five  to 
forty  years.  It  becomes  constantly  rarer  in  later  years;  it  is 
found  after  sixty  only  exceptionally.  Observations  of  paresis 
in  childliood  and  youth  have  accumulated  in  the  last  decennia.^ 
In  these  cases  hereditary  syphilis  may  be  demonstrated  almost 
constantly.  Paresis  in  both  husband  and  wife  is  often  observed 
(conjugal  paresis).^  In  about  75  per  cent,  of  all  cases  of  paresis 
the  anamnesia  reveals  an  acquired  syphilis  on  an  average  of  from 
ten  to  fifteen  years  before  the  outbreak  of  the  disease.  Since  the 
population  living  under  similar  circumstances  and  of  the  same 
age  show  only  about  15  to  18  per  cent,  of  cases  of  syphilis,  and 
parallel  statistics  show  similar  results  in  different  places,  it  is 
not  improbable,  then,  to  assume  that  syphilis  plays  a  considerable 
part  in  the  causation  of  paresis.  But  that  it  is  a  tertiary  syphi- 
litic disease  of  the  brain  or  a  metas^-philitic  nerve  lesion,  is  con- 
troverted by  the  fact  that  syphilitic  changes  cannot  be  shown  in 
the  brain  or  other  organs  in  tlie  great  majority  of  cases ;  further, 
because  the  anti-syphilitic  treatment  is  without  results,  and, 
above  all,  that  a  not  insignificant  percentage  of  cases  exist  in 
which  syphilis  has  certainly  not  preceded  the  paresis.     S\Tphilis 


^  Jahrmarker.     Zeitschrift  fiir  Psvchiatrie.  vol.  Iviii. 

^  Alzheimer.     Zeitschrift  fiir  Psvchiatrie.  vol.  lii. 

^  Monkemoller.     ^lonatschrift  fiir  Psycliiatrie,  December,   1900. 


The  Organic  Fsijclioses:  rarcsis.   263 


forms   only   the    predisposing   momentum,   the   foundation    on 
which  a  classical  paresis  arises  in  the  great  majority  of  cases. 

The  lesions  which  really  call  forth  the  paresis  could  not 
generate  the  disease  unless  the  nervous  system,  especially  the 
brain,  had  suffered  a  change  from  the  preceding  syphilitic  in- 
fection which  makes  it  incapable  of  resistance  to  those  lesions. 
What  this  change  consists  of  is  not  known  at  present;  perhaps 
it  lies  in  the  walls  of  the  finest  arterioles  and  capillaries  and  the 
disturbances  of  endosmosis  and  exosmosis  conditioned  by  them. 

In  some  cases  hereditary  basis  forms  the  predisposition, 
but  by  no  means  to  the  same  extent  or  importance  which  was 
due  to  it  in  the  functional  psychoses. 

The  immediate  inciting  causes  lie  in  a  great  number  of  cases 
in  psychic  momenta :  sorrow,  care,  disappointed  hope,  losses  suf- 
fered, too  great  psychic  exertion  for  the  individual;  further, 
debauches  with  wine  and  women,  but  especially  the  misuse  of 
alcohol ;  and,  finally  in  single  cases,  traumata  of  the  head. 

The  outhreah  of  the  disease  is  never  acute,  certain  pro- 
dromata  of  development  always  precede  it. 

The  course  of  paresis  is  invariably  chronic,  excepting  the 
galloping  form,  which  is  generally  masked  by  the  type  of  acute 
delirium.  The  disease  runs  most  frequently  as  the  demented 
form  (in  about  two-thirds  of  all  cases).  The  cases  of  classic 
paresis  are  becoming  constantly  rarer  in  modern  times. 

The  progressive  course  is  often  interrupted  by  remissions, 
especially  in  the  classic  and  depressive  types,  also  in  the  ascend- 
ing form.  The  remissions  may  give  the  impression  of  recovery, 
and  may  last  months,  a  year  or  longer.  A  certain  decrease  of 
the  former  energy  and  greater  susceptibility,  as  a  rule,  cannot 
be  misunderstood.  Married  women  sometimes  think  their 
paretic  husbands  healthier  psychically  under  these  conditions 
than  they  were  before  the  disease  appeared. 

The  duration  of  the  disease  amounts,  on  an  average,  in  men 
from  three  to  four  years;  in  women,  from  four  to  five  years. 
Two-thirds  of  the  paretic  men  die  before  the  end  of  the  second 
year,  exceptionally  there  is  a  duration  of  from  eight  to  ten  years, 
or  even  lonsier.^ 


^Liistig.    Zeitschrift  fiir  rsrchiatrie,  vol.  h-ii. 


264  Special  Psychiatry. 


Fiesidts.     The  results  of  the  paresis  are : 

1.  Eecovery,  which  is  extremely  rare,  though  it  has  undoubt- 
edly been  observed.  As  a  rule,  so-called  recoveries  are  only  re- 
missions of  exceptional  duration. 

2.  Death,  which  occurs  in  half  the  cases  in  the  paralytic 
attack  or  by  decubitus,  cystitis,  hypostatic  pneumonia,  exhaus- 
tion; further,  by  accidents  (suffocation  in  consequence  of  eso- 
phageal paralysis,  wounds  and  their  sequelse),  sometimes  by  self- 
destruction  in  the  first  stage. 

Pathological  Anatomy. 

The  most  frequent  macroscopic  finding^  is  the  disappearance 
of  the  diploe  with  hypertrophy  of  the  bones  of  the  cranium, 
greater  weight  of  the  calvarium,  external  and  internal  pach}-- 
meningitis,  thickening  and  simple  clouding  of  the  arachnoid 
(also  milky  clouding),  especially  in  the  cephalic  part  of  the 
brain,  adherence  of  the  arachnoid  to  the  cortex,  also  to  the  dura 
and  the  calvarium  (especially  in  the  region  of  the  central  con- 
volutions), atrophy  of  the  cortex,  preferably  in  the  frontal  lobes, 
rarer  in  the  other  lobes,  granulations  of  the  epend3'-ma,  external 
and  internal  hydrocephalus. 

The  weight  of  the  brain  is  generally  diminished,  the  right 
hemisphere  is  usually  heavier  than  the  left. 

Microscopically^  one  finds  in  the  chronically  running  par- 
al3'ses  of  the  brain  cortex,  increase  of  the  nuclei  of  the  neuroglia, 
swelling  of  the  glia  cells  with  abundant  ramifications,  the  neu- 
roglia thickened,  sometimes  transformed  into  fibers  and  shriv- 
eled. The  nerve  cells  are  atrophied,  sclerotic,  often  pigmented, 
and  show  loss  of  chromophil  substance.  Disappearance  of  the 
nerve  fibers,  especially  of  the  tangenital  fibers  first  (Tuczek),  is 
regularly  present.  There  are  similar  changes  in  the  large  basal 
ganglia,  especially  in  the  thalamus  opticus  (Lissauer),  also  in 
the  cerebellum  (Weigert).  The  vessels  are  often  atheromatous, 
hyalin  degeneration  is  rare;  in  the  capillaries  there  is  more  or 
less  dilatation  of  the  lumina  with  enlargement  of  the  nuclei  and 


^  Nacke.  Makroskopische  Hirnbefunde  bei  mannliclien  Paralvtikeni. 
Zeitschrift  fiir  Psychiatrie,  vol.  Ivii,  619,  1900. 

^  Binswanger.  Pathologische  Histologie  der  Grossliirnrindenerkran- 
kung.     Jena,  1893. 


Tlie  Orgaiilr  Psijclioses:  rarenis.  2G5 

tliickening  of  the  walls  (Kronthal),  there  is  often  a  new  growth 
of  the  vessels. 

Focal  diseases  are  rare. 

The  spinal  cord^  shows  regularly  changes  which  have  existed 
for  a  long  time:  degeneration  of  the  posterior  white  columns  or 
lateral  tracts,  generally  combined  scleroses  (Filrstner),  second- 
ary degeneration  of  the  pyramidal  tracts;  diffuse  myelitis.  De- 
generative processes  of  the  anterior  and  posterior  roots  and  of 
the  peripheral  nerves,  including  the  cranial  nerves,  especially 
the  opticus,  are  frequent. 

Wliether  the  described  findings  have  their  point  of  depart- 
ure in  the  vascular  system  (encephalitis  interstitialis  diffusa), 
which  I  accept  for  the  great  majority  of  the  cases,  and  which 
has  lately  been  advocated  by  Eobertson,  or  whether  it  is  a  primary 
degenerative  process  of  the  nerve  elements,  or  whether,  finally, 
the  infective  cause  attacks  vascular  walls  and  nerves  contempo- 
raneously, cannot  be  absolutely  decided  at  this  time. 

Perhaps  the  diverse  clinical  types  and  the  varied  course 
which  they  follow  may  be  explained  by  the  difference  of  the  ana- 
tomical development. 

Diagnosis.  The  advanced  paretic  very  often  reveals  the 
diagnosis  the  moment  he  enters  the  room  by  the  simple  expres- 
sion of  his  countenance,  his  helpless  movements,  his  odd  greeting, 
with  the  characteristic  speech. 

In  the  earlier  stage  one  should  observe  in  the  differential 
diagnosis: 

].  The  fimctional  psychoses,  especially  mania,  depressive 
states,  circular  psychoses,  exceptionally  paranoia.  Here  are 
decisive : 

(a)  The  presence  of  mental  weakness,  which  is  foreign  to 
the  functional  psychoses  before  their  passing  into  dementia  and 
which  cannot  be  mistaken  even  in  the  earlier  stages  of  paresis. 

(h)  Above  all,  the  proof  of  paretic  symptoms,  especially  the 
disturbances  of  the  reflexes  (reflex  rigidity  of  the  pupils,  ab- 
sence of  the  patellar  reflexes),  and  of  the  disturbances  of  speech 
which  are  peculiar  to  paresis. 


^  Ftirstner.     Arcliiv  fiir  Psychiatrie,  vol.  xxxiii,  939. 


266  Special  Psychiatry. 


(c)  The  entrance  of  paralytic  attacks,  which  in  doubtful 
cases  sometimes  confirm  the  diagnosis  of  paresis. 

2.  The  intoxication  psychoses.  Chronic  alcoholism  is  to  be 
specially  mentioned  in  this  connection  (see  alcoholic  pseudo- 
paresis).  In  addition,  paresis  may  arise  on  the  basis  of  chronic 
alcoholism,  and,  on  the  other  hand,  a  paresis  may  incite  to  alco- 
holism by  the  psychic  change. 

Of  the  chronic  intoxications  the  following  are  important 
in  a  differential  diagnosis :  intoxications  with  bromide,  sulfonal, 
trional.  These  drugs  may,  by  immoderate  use,  bring  on  de- 
mentia, great  diminution  of  the  memory  and  of  the  attention, 
loss  of  the  patellar  reflexes,  ataxia,  even  a  disturbance  of  speech 
similar  to  the  paretic.  Yet  the  reflex  rigidity  of  the  pupils  is 
wanting.  The  improvement  which  will  regularly  follow  the 
removal  of  the  poison  will  confirm  the  diagnosis. 

Encephalopathia  saturnina  may  be  distinguished  from  pare- 
sis by  reference  to  the  anamnesia,  the  proof  of  lead  colic  and 
lead  palsy,  the  moderate  and  non-progressive  dementia.  In 
this  encephalopathia,  the  joaralytic  disturbances  of  speech  are 
generally  wanting,  also,  as  a  rule,  the  pupillary  anomalies. 

Uremia,  which  may  simulate  the  picture  of  paresis,  is  dis- 
tinguished by  the  frequent  vomiting,  by  the  asthma,  by  the 
nature  of  the  urine  (albumin  and  casts),  retinitis  albuminurica, 
by  the  absence  of  the  reflex  rigidity  of  the  pupils  and  the  speech 
disturbance  of  paresis. 

3.  In  regard  to  the  organic  brain  diseases  the  following 
sJiould  be  accentuated  differentio-diagnostically : 

(a)  For  syphilitic  brain  disease,  point  continuous  paralyses 
of  the  eye  muscles  in  the  anamnesia  as  well  as  in  the  later  stages 
(only  transitory  palsy,  as  a  rule,  with  paresis),  neuritis  optica 
(in  paresis  simple  primary  atrophy  of  the  opticus,  neuritis  op- 
tica, rare),  transitory  hemiplegias,  transitory  and  interchang- 
ing monopareses  and  monospasms  and  frequent  changes  of  the 
psychic  phenomena.  There  is  also  generally  lacking  in  syphi- 
litic diseases  of  the  brain  a  dififuse  h^'palgesia  or  analgesia ;  the 
disturbances  of  speech  and  writing  are  not  so  accentuated  as  in 
paresis. 

If  secondary  or  tertiary  s}Tnptoms  of  syphilis  are  present  in 
tlie  organs  or  on  the  skin,  they  will  indicate  brain  sA-philis  as 


Tlte  Organic  Psijchoses:  I'aresis.  267 


against  paresis.  At  the  age  of  thirty  or  under,  one  must  think 
more  of  syphilis  than  of  j^aresis. 

(h)  For  dementia  senilis  as  against  paresis,  the  advanced 
age,  sixty-five  years  or  over,  will  he  the  index;  the  jjeculiar  dis- 
turbances of  the  memory  in  which,  with  good  recollection  of 
things  long  past,  the  power  of  observation  of  what  has  just  oc- 
curred has  been  lost,  further,  the  generally  depressed  and  very 
irritable  peculiar  disposition  of  those  suffering  from  senile  decay 
are  characteristic,  while  the  advanced  paretic  is  distinguished 
mostly  by  his  easy  susceptibility.  Besides  this,  senile  dementia 
usually  follows  a  much  slower  course  than  paresis,  is  distin- 
guished by  great  variations  in  the  psychic  condition,  absence  of 
paralytic  disturbance  of  speech,  and  the  relative  rarity  of  reflex 
rigidity  of  the  pupils. 

There  are,  however,  cases,  especially  between  sixty  and 
sixty-five  years,  in  which  it  is  impossible  to  make  the  diagnosis 
with  certainty. 

(c)  For  focal  diseases  of  the  brain,  as  against  paresis,  point 
definite  focal  phenomena  which  are  wanting  in  paresis,  or  which 
appear  only  f;ransitorily  in  connection  with  paralytic  attacks. 
However,  there  are  also  pareses  which  are  complicated  with  focal 
diseases  (apoplectic  foci). 

With  focal  diseases  of  the  brain  there  is  generally  present 
a  strong  feeling  of  disease,  and  it  is  seldom  that  so  profound  a 
dementia  is  developed  as  in  paresis. 

If  multiple  focal  diseases  of  the  brain  and  of  the  spinal  cord 
are  present  (as,  e.g.,  in  multiple  sclerosis  or  in  syphilitic  brain 
tumors),  the  diagnosis  may  be  A^ery  difficult  or  impossible  in  the 
advanced  stages.  Here,  generally,  only  the  anamnesia  can  be 
decisive. 

The  prognosis  of  paresis  is  unfavorable,  yet  the  possibility 
of  the  entrance  of  prolonged  remissions  should  not  be  overlooked. 

The  posterity  of  paretics  often  show  abnormalities  of  mental 
development,  sometimes  they  become  severely  diseased  psychi- 
cally. Quite  often  physical  and  mental  stigmata  of  degenera- 
tion are  found  in  such  descendants  in  a  marked  degree. 

The  marriages  of  paretics  are  unfruitful  in  a  relatively  large 
percentage  of  the  cases  (about  25  per  cent.),  while  the  number  of 


26S  Special  Psychiatry. 


childless  marriages  in  the  population  amounts  to  only  10  to  12 
per  cent,  on  the  average. 

Treatment.  The  paretic  suffering  from  the  demented  form 
should,  sometimes,  in  the  earlier  stages  of  the  disease,  be  placed 
in  an  institution  on  account'  of  his  inclination  to  immoral  actions. 
This  is  desirable  in  advanced  dementia  when  the  patient  cannot 
have  the  necessar}'  attention  and  care  at  home. 

The  depressive  and  maniacal  stages  of  the  disease  need  treat- 
ment in  an  institution,  in  the  same  way  as  do  the  patients  suffer- 
ing from  melancholia  and  mania. 

If  previous  syphilis  is  shown  in  a  paretic,  if  the  dementia 
is  not  yet  far  advanced,  and  if  he  has  not  suffered  much  in  his 
nutrition  so  far,  one  should  try  the  inunction  treatment  (two  to 
three  grams  of  unguentum  cinereum  daily  until  the  entire  quan- 
tity of  120  grams  is  used). 

The  cases  in  which  an  improvement,  or  only  a  stationary 
period  is  reached  by  this  treatment  or  by  the  use  of  iodine  or 
ergot,  belong  to  the  rare  exceptions.  Visiting  bathing  resorts 
is  useless,  and  injurious  both  from  the  excitement  of  going  and 
of  being  in  strange  places. 

Baths  at  90°  F.,  also  with  the  addition  of  from  2  to  3  kilo- 
grams of  common  salt,  are  recommended  with  home  or  institu- 
tion treatment. 

Surgical  operations  should  be  discouraged  (trephining  has 
produced  no  satisfactory  results). 

The  treatment  can  but  regard  the  momentary  condition, 
and  therefore  be  only  symptomatic.  Nutritious  food  with  abund- 
ant milk  should  be  provided;  careful  cleaning  of  the  patient, 
decubitus  if  it  arises,  special  care  be  given  to  the  bladder  and 
bowels  are  the  only  indications.  In  states  of  excitement  rest  in 
bed  is  recommended;  as  Iwpnotics,  trional,  sulfonal,  chloral, 
and  morphine  injections  are  useful. 

(b)   Senile  Dementia,  Senile  Atrophy  of  the  Brain.i 

Senile  dementia  begins,  as  a  rule,  with  insomnia,  attacks 
of  dizziness  which  may  reach  the  summit  of  epileptic  states, 


^Alzheimer.  Sammelreferat  in  Moiiatschrift  fiir  Psycliiatrie.  1898. 
Wille.  Zeitschrift  fiir  Psycliiatrie,  vol  xxx.  Fiirstner.  Archiv  fiir 
Psycliiatrie,  1889,  xx. 


The  Organic  Psychoses:  Senile  Dementia.  269 


fainting  spells,  paresthesias  of  the  hands  and  feet  with  irascible 
and  irritable  disposition,  diminution  of  the  memory,  especially 
for  recent  events,  while  for  past  events  it  is  faithful,  sometimes 
astonishingly  so.  Commingled  hypochondric  complaints  arise, 
egotistic  impulses  rule,  while  altruistic  feelings  are  crowded 
more  into  the  background.  Hence  the  pronounced  avarice  to- 
wards others,  sometimes  contemporaneous  with  senseless  lavish- 
ness  on  his  own  enjoyments.  In  the  last  respect  especially,  erotic 
impulses  arise,  and  large  sums  are  squandered  for  the  gratifica- 
tion of  this  passion;  sometimes  promises  of  marriage,  marriage 
itself  without  regard  to  station  or  children,  proceed  therefrom. 

Severe  psychic  symptoms  of  a  pathological  nature  appear 
mostly  at  night.  The  patient  does  not  go  to  bed  or  soon  rises, 
busies  himself  about  the  house,  locks  up  everything,  barricades 
himself,  has  transitory  illusions  and  hallucinations  of  people 
who  wish  to  break  in  or  of  such  as  go  to  the  other  spouse  in  order 
to  commit  immoral  actions  during  the  night. 

During  the  day  the  patient  speaks  of  the  fancied  or  hallu- 
cinated occurrences  as  facts,  while  otherwise  he  seems  to  be  fully 
oriented  and  may  seem  mentally  normal  externally.  On  the 
basis  of  his  pathologically  changed  relations  to  the  outer  world 
he  changes  his  will  quite  often,  makes  new  ones;  the  belief  that 
his  children  wish  his  death,  or  attempt  to  hasten  it,  is  so  height- 
ened that  his  relatives  often  argue  with  him  in  opposition  and 
try  to  hinder  him  from  doing  many  absurd  things.  The  mem- 
ory, well-preserved  for  events  which  took  place  long  ago,  even  in 
youth,  is  the  proof  which  is  often  cited  by  the  witnesses  as  to  the 
validity  of  the  testament,  and  often  regarded  by  them  as  proof 
of  normal  mentality.  In  this  stage  there  are  quite  often  im- 
moral actions  (stealing),  also  in  regard  to  offenses  against 
decency. 

In  the  further  course  there  is  garrulousness,  confabulation 
with  considerable  diminution  of  the  intelligence,  and  lack  of 
orientation  in  regard  to  time  and  space,  fear  if  left  alone,  help- 
less if  unaccompanied  on  the  streets,  neglect  of  social  require- 
ments in  dress,  in  regard  to  eating  and  drinking,  soiling  the 
clothes  and  bedding  through  the  imperfect  closure  of  the  sphinc- 
ters. 


270  Special  Psychiatry. 


Apoplectiform  attacks  in  tiieir  turn  make  the  mental  condi- 
tion "worse. 

The  final  stage  is  an  apathetic  idiocy,  in  which  the  old 
man  finall)-  becomes  a  child  again. 

With  regard  to  the  somatic  disturbances,  a  senile  dementia 
with  or  without  focal  s}"mptoms  must  be  distinguished.  Senile 
dementia  with  focal  symptoms  shows  hemiplegias,  also  para- 
plegias which  owe  their  origin  to  apoplectic  extravasations  or 
thrombotic  centers  of  softening. 

Special  Symptomatology. 

Illusions  and  hallucinations  are  frequent  in  the  earlier 
stages  of  senile  dementia,  especially  in  the  visual  sense.  Transi- 
torily, there  are  massive  hallucinations  in  all  the  senses,  with  con- 
siderable clouding  of  the  consciousness.  Such  states  appear 
especially  at  night. 

The  intelligence  gradually  crumbles  away.  There  are  often 
melancholic  delusions,  delusions  of  transgression,  more  frequently 
h^'pochondric,  sometimes  maniacal  and  hypo-maniacal  states 
appear;  finalh',  paranoic  delusions  with  a  persecutory  and  ex- 
pansive content.  In  the  last  case  grandiose  ideas  may  be  asso- 
ciated with  these  delusions. 

There  is  often  a  rapid  inversion  of  the  actions  by  sudden 
impulses  which  are  not  opposed  by  inhibition.  The  violence  of 
these  last  stand  out  in  strong  contrast  to  the  former  want  of 
energy. 

The  disturbances  of  the  memory  have  been  discussed.  The 
question  here,  especially  at  the  beginning  of  senile  dementia,  is 
preferably  of  a  diminution  of  the  power  of  attention:  hence  the 
patients  do  not  know  that  they  have  just  eaten,  that  they  have 
just  made  a  visit,  or  what  they  have  just  been  doing. 

Somatic  Symptoms. 

The  furrowed  brow,  the  wrinkled  face,  the  stooped  frame, 
the  shuffling  gait,  trembling  of  the  head,  of  the  tongue,  of  the 
hands,  and  in  the  later  stage  the  paralyses  of  the  extremities, 
are  all  common  concomitant  symptoms  of  senile  dementia.  With 
this  there  is  marked  contraction  and  Inequality  of  the  pupils, 


The  Organic  Psychoses:  Senile  Dementia.  271 

seldom  reflex  rigidity  of  the  same  (Siemerling and Moeli), prompt 
tendon  reflexes  which  decrease  in  power  kiter,  and  diminution 
of  the  skin  reflexes.  In  the  more  advanced  stages  paralysis 
of  the  bhidder  and  rectal  reflexes  develops.  Moreover,  there  are 
present  the  ordinary  changes  of  old  age,  especially  in  the  organs 
of  sense  and  in  the  vascular  system. 

The  incipient  agrypnia  gives  place  later  to  long  and  lasting 
sleep.  Narcoleptic  attacks  are  often  observed,  the  patients 
sleep  during  the  day  Avithout  reference  to  time  or  place,  while 
on  the  other  hand  they  are  sleepless  at  night. 

As  in  paresis,  paralytic  attacks  also  appear  here. 

Etiology. — Senile  dementia  does  not  begin  as  a  rule  before 
the  sixty-fifth  year,  in  women  generally  somewhat  later.  The 
premature  appearance  of  the  changes  in  the  brain  due  to  old 
age,  and  the  immoderate  develoiDment  of  the  same,  which  senile 
dementia  conditions,  may  be  called  forth  before  the  age  of  sixty- 
five  by  heredit}^  by  severe  bodily  disease,  by  abuse  of  spirits,  by 
psychic  causes  (sorrow,  care,  loss  of  wife  or  husband). 

The  course  of  senile  dementia  is  sometimes  protracted,  last- 
ing ten  years  and  even  longer,  often  showing  remissions  and  ex- 
acerbations. The  result  is  death,  which  may  come  suddenly  in 
an  apoplectiform  attack,  or  gradually  by  marasmus.  Sometimes 
death  by  suicide  occurs,  especially  in  the  first  stage  of  senile 
dementia.  An  intercurrent  disease  often  hastens  the  end 
(pneumonia). 

Pathological   Anatomy. 

The  characteristic  change  of  senile  dementia  consists  of  a 
general  sclerosis  of  the  arteries  of  the  brain,  often  with  hyalin 
fibrous  degeneration.  Sometimes  the  great  vessels  are  intact 
while  the  small  vessels  and  capillaries  are  diseased.  There  is 
an  attenuation  of  the  bones  of  the  cranium,  the  cliploe  is  visible 
(malum  senile),  generally  external  and  internal  pach3'meningi- 
tis  are  present,  quite  often  with  hematomata,  clouding  of  the 
arachnoid  inlaid  with  calcareous  plaques,  large  Pacchionian 
granulations,  atrophy  of  the  brain  cortex,  especially  of  the  frontal 
lobes,  and  granulations  of  the  ependyma.  In  a  third  of  all  cases 
there  is  hemorrhagic  or  thrombotic  softening  of  the  brain;  fur- 
ther, sclerotic  changes  in  the  spinal  cord.     Microscopically,  the 


272  Special  Psychiairy. 


atrophic  brain  shows  h3'pertrophy  of  the  neuroglia,  sometimes 
"with  miliary  sclerosis  of  the  cerebral  cortex,  disappearance  of 
the  tangential  fibers,  decrease  of  the  numl^er  of  the  nerve  cells 
of  which  those  present  are  atropho-pigmentous,  and  fatty  degen- 
eration with  chromatolysis.  The  smallest  vessels  and  capillaries 
often  seem  destroyed,  sometimes  changed  into  strings  without 
lumen.  The  peripheral  nerves  often  show  signs  of  a  degenera- 
tive neuritis. 

The  diagnosis  must  take  into  consideration  the  fact  that  not 
every  psychosis  which  appears  in  old  age  is  senile  idiocy.  All 
other  forms  of  psychic  disease,  cren  curable  ones,  may  appear  in 
old  age.  The  slow  development,  the  peculiar  disturbances  of 
memory,  as  well  as  the  progressively  increasing  psychic  weakness, 
are  decisive  diagnostic  features. 

Senile  dementia  is  distinguished  from  the  focal  diseases  of 
the  brain  by  the  absence  of  focal  symptoms,  or  where  such  are 
present,  by  the  course,  especially  when  the  late  appearance  of 
focal  symptoms  developed  after  the  psychic  disturbance  was 
plainly  manifest. 

The  prognosis  is  unfavorable. 

The  treatment  should  be  symptomatic.  The  usual  stimu- 
lants should  not  be  cut  off;  coffee,  beer,  wine  should  be  allowed 
moderately.  For  sedation,  morphine  injections  may  be  used, 
or  opium  internally,  and  camphor  injections  to  overcome  initial 
states  of  weakness. 

The  restlessness  of  the  patients  and  their  inclination  to  im- 
moral actions,  the  lack  of  superintendence  and  nursing  at  home 
with  the  poorer  population,  will  give  the  indications  for  taking 
the  sufferers  from  senile  dementia  to  an  institution. 

(c)   Arteriosclerotic  Psychoses.^ 

On  the  basis  of  a  rapidly  developing  sclerosis  of  the  arterial 
system,  especially  in  men  of  from  fifty-five  to  sixty  years  of  age 
with  palpitation  of  the  heart,  accelerated  or  intermitting  pulse, 
with  small  albuminuric  contents  of  the  urine,  the  type  of  simple 
melancholia,  with  attacks  of  anxiety,  self-reproaches,  and 
thoughts  of  suicide,  arises  which  will  again  pass  away  in  the 


^  Alzheimer.    Sammelreferat.    ^Monatsschrif t  fur  Psychiatrie,  1898. 


Tlie  Organic  Psychoses:  Arteriosclerosis.  273 


course  of  a  few  months.  During  this  lime  the  alterations  in  the 
vascuhir  system,  wliich  were  not  observed  before,  are  apt 
to  manifest  themselves  plainly  (climacteric  of  men).  In  other 
cases  the  arteriosclerosis  leads  to  brain  atrophy  only,  either  under 
the  type  of  senile  dementia  where  only  the  relatively  youthful 
age  (fifty-five  to  sixty  years)  is  striking  {premature  senescence) , 
or  under  the  type  of  the  demented  form  of  paresis.  From  this 
it  is  distinguished  by  its  later  appearance,  the  lack  of  the  reflex 
rigidity  of  the  pupils,  of  the  paralytic  disturbance  of  speech,  the 
development  to  a  high  degree  of  the  arteriosclerotic  phenomena 
in  the  full,  bounding  arteries,  in  the  heart,  the  kidneys  (arteri- 
osclerotic atrophied  kidney),  the  moderate  degree  of  weakmind- 
edness  with  much  disturbed  memory  and  a  strong  feeling  of 
disease  with  the  absence  of  clearly  defined  delusions,  and  the 
very  slow,  unprogressive  course. 

The  treatment  of  these  states  consists  in  combating  the 
arteriosclerosis. 

In  the  course  of  paralysis  agitans  melancholic  conditions 
are  often  observed ;  after  they  have  remained  for  a  long  time  the 
sym2:)toms  of  senile  dementia  often  appear.  Acute  encepflalitis 
JiemorrJiagica  sometimes  runs  under  the  clinical  type  of  deli- 
rium acutum. 

Pachymeningitic  Psychoses. 

Pachymeningitis,  with  or  without  hematoma,  may  accom- 
pany the  various  forms  of  brain  disease. 

Where  it  is  the  essential  anatomical  basis  of  the  psychosis, 
the  disease  runs,  after  beginning  with  severe  headaches,  Avith 
profound  depression,  Aveakness  of  the  memory  and  the  intelli- 
gence, sometimes  a  very  slow  course  and  remains  stationary  for 
years;  in  other  cases  more  rapidly,  with  vomiting  and  intercur- 
rent paralytic  states,  ending  in  death.  Such  cases  appear  in 
alcoholists,  after  trauma,  in  tuberculous  and  cachectic  indi- 
viduals. 

(d)   Syphilitic   Psychoses.^ 

Syphilis  as  an  etiological  factor  has  already  been  con- 
sidered. 


Jolly.    Kliiiisclie  Woclienschrift  1,  1901. 

18 


274  Special  Psychiatry. 


Organic  s}-philitic  ps3'choses  may  be  conditioned: 

1.  By  syphilitic  disease  of  the  cerebral  arteries  (endarteritis, 
periarteritis,  periarteritis  with  following  thrombosis  and  foci 
of  softening). 

2.  By  gummatous  tumors  of  the  brain. 

3.  By  diffuse,  often  multiple,  syphilitic  disease  of  the  brain 
and  its  envelopes  (meningoencephalitis  gummosa,  syphilitic  local 
meningitis  diffusing  itself  from  the  trigonum  intercrurale).  In 
many  cases  the  various  types  are  present  in  combination. 

A  preliminary  stage  with  headaches,  disturbed  sleep,  pa- 
ralj^ses  of  the  muscles  of  the  eye,  transitory  paralyses  of  the  ex- 
tremities, partial  disturbances  of  the  vision  are  common  to  the 
respective  diseases. 

In  its  further  course  the  clinical  type  is  very  different,  cjuite 
often  changing  in  respect  to  the  somatic  sjTnptoms,  on  account  of 
the  various  localizations  and  tiie  diffusion  of  the  pathological  pro- 
cess. Apoplectic  and  apoplectiform  attacks,  especially  with  right 
hemiplegia  and  aphasia  (endoarteritis  art.  foss.  Sylvii  sinistr.), 
Jacksonian  epilepsy,  epileptoid  states  with  intoxication-like  con- 
fusion and  hallucinations,  and  epileptic  seizures  are  quite  com- 
mon. The  disturbances  of  speech  have  usually  the  character  of 
dysphasias  and  d3'sarthrias,  not  of  syllable-stumbling.  With 
reference  to  the  ps3'chic  condition,  a  diminution  of  the 
intelligence  and  of  the  memory  is  common  to  the  organic  psy- 
choses conditioned  by  syphilis.  Herewith  may  be  associated 
states  similar  to  the  symptoms  of  a  delirium  hallucinatorium, 
a  hj^pochondric  melancholia,  and  changes  of  maniacal  excite- 
ment and  depression ;  in  rarer  cases  a  paranoic  mania  may  arise. 
In  a  gTcat  number  of  cases  the  disease  runs  under  the  type  of  pro- 
gressive dementia  (pseudoparesis  syphilitica,  Foumier). 

For  the  differential  diagnosis,  see  Paresis. 

In  many  cases,  especially  after  anti-s^^philitic  treatment, 
the  disease  remains  stationary;  there  remains,  however,  a  state 
of  mediocre  psychic  weakness  and  a  lack  of  bodily  energy. 

Sometimes  the  outbreak  of  a  syphilitic  psychosis  suddenly 
follows  an  apoplectic  attack  or  epileptic  seizure. 

The  course  and  duration  of  the  psychosis  are  determined 
by  the  localization  and  diffusion  of  the  s^-philitic  process. 

The  prognosis  is  always  doubtful,  since  the  effect  of  the 


The  Organic  Psychoses:  Apoplexy.  275 


specific  treatment  cannot  always  be  estimated  with  absolute  cer- 
tainty. 

The  treatment  is  that  for  syphilis,  where  long-continued 
dosage  of  the  specific  remedy  is  to  be  preferred  to  those  which 
are  too  energetic  (unguent,  ciner.  in  doses  of  3  grams  per  day 
to  a  total  quantity  of  150  grams).  If  mercury  is  without  effect, 
the  iodide  of  potassium  treatment  should  be  tried  in  large  doses 
(1.5  to  4.0  grams  twice  a  day)  or  iodipin  (a  teaspoonful  three 
times  daily).  Sometimes  treatment  with  Zittmann's  decoction 
is  effective  in  obstinate  cases.  Cold-water  cures  are  to  be  recom- 
mended in  the  after-treatment. 

Through  hereditary  syphilis  there  may  arise: 

1.  States  of  imbecility  and  idiocy. 

2.  Paresis  in  children. 

3.  Familiar  progressive  dementia  (Homen),  beginning  at 
the  age  of  twelve  to  twenty  years,  with  a  feeling  of  exhaustion, 
headaches,  dizziness,  later  ataxia,  trembling,  contractures,  slow- 
ness of  speech,  diminution  of  the  intelligence  and  of  memory. 

In  all  these  cases  the  inunction  cure  is  strongly  recom- 
mended. 


2.  Psychoses  Which  Are  Called  Forth  by  Focal  Diseases 
of  the  Brain. 

(a)  Psychoses  After  Apoplectic  Attacks. 

Brain  apoplexies  often  evoke,  with  considerable  weakening 
of  the  intelligence  and  of  memory,  a  great  irritability,  weeping 
disposition;  then,  again,  loquacity,  easy  susceptibility,  uncon- 
querable obstinacy  in  individual  matters.  Sometimes  the  abnor- 
mal disposition  expresses  itself  especially  in  sexual  perversions 
(indecent  attempts).  Melancholic  or  melancholio-hypochron- 
dric  depression,  paranoic  delusions  often  develop  on  this  basis. 
Eepeated  apoplectic  attacks,  especially  in  consequence  of  embol- 
ism and  thrombosis  with  softening  processes  following,  quite 
often  lead,  in  regard  to  psychic  phenomena,  to  a  pathological  type 
which  is  similar  to  senile  dementia,  while  it  shows  somatically 
the  symptoms  of  focal  disease    (aphasia,  hemiplegia,  hemian- 


276-  Special  Psychiatry. 


opsia).  A  state  of  aphasic  confusion  may  arise  transitorily  both 
after  the  hemorrhagic  and  after  the  throml^otic  or  embolic  form 
of  apoplexy  (obscurity  of  the  consciousness  with  defects  of  mem- 
cry  and  paraphasic  disturbance  of  the  speech) . 

(b)   Psychoses  Which  Are  Produced  by  Brain  Tumors.i 

To  be  considered  are  gliomata,  sarcomata,  carcinomata, 
fibromata,  cholesteatomata,  and  tubercles  of  the  brain. 

Besides  the  physical  symptoms,  choked  disc,  headaches,  diz- 
ziness, nausea  and  vomiting,  abnormal  psychic  states  develop, 
characterized  by: 

1.  Hallucinations,  appearing  at  different  times  and  quickly 
disappearing,  sometimes  connected  with  the  localization  of  the 
tumor  (visual  hallucinations  in  tumors  of  the  occipital  lobe), 
and  are  often-  recognized  as  deceptions. 

2.  The  diminution  of  intelligence  and  of  memory,  often 
expressed  as  a  certain  laziness,  indolence,  and  forgetfulness,  a 
certain  stupidity  with  a  peculiar  blank  expression  of  the  count- 
enance.   Sometimes  a  silly,  foolish  state,  moria,  appears. 

3.  A  certain  yielding  disposition,  facile  irritability,  laugh- 
ing, weeping. 

Perfected  clinical  types  with  massive  hallucinations,  with 
melancholic  or  paranoic  delusions,  epileptoid  twilight  states  are 
rare ;  of tener  there  is  progressive  dementia,  especially  when  there 
are  multiple  foci. 

As  a  rule,  the  psj^chic  disturbances  of  brain  tumors  are  dis- 
tinguished bj^  being  generally  connected  with  considerable  feel- 
ing of  disease  and  by  the  appearance  of  more  or  less  clearness 
in  the  intervals  between  the  attacks,  where  delusions  and  sense 
deceptions  are  abundantly  produced. 

States  of  psychic  alteration,  similar  to  those  produced  by 
the  above-described  tumors,  may  be  brought  on  by  cysticercus, 
echinococcus  (here  epileptic  seizures  are  especially  frequent; 
one  should  examine  for  cysticercus  of  the  skin  and  the  eye), 
lirain  abscess  (here  especially  hallucinatory  deliria)  and  mul- 
tiple sclerosis. 

A  local  diagnosis  cannot  be  made  from  the  psychic  disease 


^Kaplan.    Xeurologisches  Centralblatt.  1897.    Gianelli,  the  same. 


The  Traumatic  Psyclioses:  Traumata.  277 

unless  it  may  be  said  in  general  that  focal  diseases  of  the  frontal 
lobes  very  frequently  call  forth  psychic  alterations. 

The  local  diagnosis  must  be  made  from  the  somatic  symp- 
toms only. 

It  may  be  observed,  moreover,  that  psychic  diseases  may 
also  be  complicated  with  brain  tumors. 

Supplement. 
Psychoses  Which  Result  from  Traumata.^ 

Traumata  may  call  forth  mental  diseases : 

1.  ^Yhen  they  injure  the  development  of  the  brain.  Thus 
imbecility  and  idiocy  may  arise  from  traumata  which  affect  the 
head  in  the  uterus  or  at  birth,  or  in  childhood. 

2.  By  bringing  on  a  pathological  condition  in  the  developed 
brain.  It  is  not  necessary  that  there  should  be  an  essential 
change  in  the  external  envelopes,  nor  a  breach  in  the  tabula 
vitrea,  a  fracture  of  the  base  of  the  cranium,  hemorrhage  in  the 
brain  or  its  membranes.  The  signs  of  cerebral  shock  (coma, 
dilated  pupils,  retarded  pulse,  and  lowered  respiration)  may  be 
wanting  immediately  after  the  trauma,  but,  as  a  rule,  they  are 
present  in  those  cases  where  a  psychosis  later  on  develops. 

3.  Without  or  with  inconsiderable  wounds  of  the  head  or 
the  body,  the  suddenness,  violence  of  the  circumstances  accom- 
panying the  wound  (explosions,  railroad  accidents,  and  the  like) 
may  call  forth  a  molecular  change  of  the  brain  which  may  lead 
to  a  psychosis  (terror  psychosis,  Kraepelin),  (railwa3'-brain). 
The  connecting  link  between  trauma  and  psychosis  is  found  in 
the  shock  which  is  attendant  upon  the  accident. 

We  distinguish  a  torpid  stage  (wan,  pale  countenance,  pu- 
pils reacting  sluggishly,  pulse  hardly  perceptible  and  irregular, 
sinking  of  the  temperature  to  97°  to  96°  F.,  cold  perspiration,  the 
patient  complains  of  cold  and  a  sense  of  fainting,  the  conscious- 
ness is  not  obscured)  from  the  stage  of  erethism,  whicli  gen- 
erally follows  (groaning  and  screaming,  anxiet}^,  nmning 
around,  acceleration  of  the  pulse  and  respiration) . 


^Guder.  Jena,  1886.  Moeli.  Archiv  fiir  Psychiatrie,  vol.  xii. 
Wille.  Archiv  fiir  Psychiatrie,  vol.  viii.  Troeger.  Friedreich's  Blatter 
fiir  gerichtliche  Medicin,  191.- 


278  Special  Psychiatry. 


Either  of  these  stages  may  also  appear  isolated. 

During  the  time  of  the  trauma  arid  for  a  shorter  or  longer 
period  after  it,  complete  amnesia  may  exist.  ,  In  other  cases  this 
amnesia  is  only  partial,  is  limited  to  details;  in  still  other  cases 
the  amnesia  aifects  also  the  occurrences  preceding  the  accident 
for  hours,  even  days  and  weeks  (retrograde  amnesia). 

The  developing  psychosis  can  be  recognized  at  once  by  the 
manifest  psychic  phenomena  folloAving  immediately  after  trauma 
to  the  head,  also  in  those  cases  of  shock  without  external  violence 
(primary  traumatic  psychosis),  or  only  after  long  inconsiderable 
prodromal  phenomena,  months  or  even  after  a  year  and  a  day 
{secondary  traumatic  psycliosis) . 

In  the  first  case  symptoms  of  a  twilight  state  are  sometimes 
connected  with  the  trauma ;  in  many  cases  this  state  recurs  peri- 
odically. The  symptoms  of  a  delirium  hallucinatorium,  or  of 
an  anxious  melancholia,  or  of  an  acute  dementia  often  appear — 
psychoses  which  generally  terminate  in  recovery.  Sometimes, 
however,  the  above  psychoses  appear  in  the  form  of  periodical 
mental  disturbances.  In  a  great  number  of  cases  a  hypochon- 
dric  or  hysterical  psj'Chosis  is  connected  with  the  trauma,  the 
former  with  headache,  pulsating  and  throbbing  in  the  head, 
great  sensibility  to  light  and  noise,  insomnia  and  vertigo,  feel- 
ing of  anxiety  with  the  most  diverse  phobias,  hopelessness,  with 
thoughts  bent  on  suicide,  but,  above  all,  complete  absence  of 
energy  and  spirit.  With  this  is  generally  found  an  accelerated 
pulse,  atheroma  of  the  vascular  walls  develops,  skin  and  tendon 
reflexes  are  exaggerated,  the  tongue,  hands,  quite  often  the  eye- 
lids, twitch,  sometimes  even  there  is  a  trembling  of  the  whole 
body.  There  is  dermography  at  times,  and  progressive  diminu- 
tion of  the  weight  of  the  body,  which  cannot  be  prevented  by  the 
taking  of  abundant  nourishment.  There  is  often  intolerance 
for  alcoholic  beverages.  The  development  of  a  hj^sterical  psy- 
chosis takes  place  with  all  the  changing  phenomena  as  they 
appear  in  psychoses  arising  on  the  basis  of  hysteria. 

Quite  often  there  is  a  combination  of  hypochondric  and 
hysterical  phenomena  which  have  been  especially  frequent  since 
the  advent  of  legal  actions,  based  on  personal  injuries,  and  gen- 
erally are  of  very  long  duration  and  very  difficult  to  cure. 

In  alcoholists,  delirium  tremens  sometimes  appears  after  the 


The  Traumatic  Psychoses:  Traumata. 279 


accident,  but  the  development  of  other  alcoholic  psychoses  may 
be  furthered  by  the  trauma. 

Where  there  is  a  long  interval  between  the  trauma  and  the 
first  evident  sign  of  the  psychosis,  it  is  quite  often  filled  by  con- 
stant headaches,  great  irritability,  sluggishness  and  aversion  to 
labor,  inclination  for  tramping,  overindulgence  in  alcohol,  which 
is,  as  a  rule,  not  kindly  tolerated.  Sometimes  such  states  pass 
into  incurable  dementia. 

■  With  a  similar  course  and  with  intercalary  maniacal  or 
melancholic  phases,  general  motor  paresis,  dementia  paralytica 
traumatica  (Koeppen),  develops. 

Finally,  paresis  may  be  generated  by  the  trauma  when  a 
predisposition  is  present  (syphilis,  alcohol,  excesses,  heredity). 

While  epilepsy  and  epileptic  psychoses  quite  often  arise  m 
children  in  consequence  of  trauma,  this  disease  appears  in  adults 
only  exceptionally,  after  the  thirtieth  year. 

In  the  cases  which  are  reported  as  belonging  to  traumatic 
epilepsy,  there  is  not,  as  a  rule,  a  classical  epilepsy,  but  an  alco- 
holic or  syphilitic  type,  in  which  the  trauma  is  only  an  auxiliary 
factor  for  the  development  of  the  disease,  or  an  organically  con- 
ditioned epilepsy  (Jackson). 

Often,  on  the  other  hand,  one  sees  epileptoid  twilight  states 
appear  periodically  after  the  trauma. 

Apoplexies,  encephalitis  hemorrhagica,  brain  abscesses,  and 
brain  tumors  may  be  caused  by  trauma,  and  the  last  may  also 
condition  psychoses  proceeding  from  those  diseases. 

4.  The  trauma  may  produce  a  psychosis  in  this  way,  that 
the  injury  proceeding  from  it,  or  the  scar  conditioned  by  its  heal- 
ing, may  bring  on  the  disease  by  reflex  irritation,  usually  with 
epileptiform    phenomena    (reflex   psychosis),    a    most   unusual 

occurrence. 

5.  The  trauma  may  create  the  predisposition  for  the  gen- 
eration of  a  psychosis,  in  that  it  diminishes  the  power  of  re- 
sistance of  the  brain. 

In  this  manner  the  psychoses,  which  sometimes  first  appear 
many  years  after  the  trauma,  should  l)e  judged,  in  which  during 
the  interval  no  noteworthy  pathological  symptoms  are  present, 
and  the  immediate  occasion  for  the  mental  disease  must  be 


280  Special  Psychiatry. 


sought,  not  in  the  trauma,  but  in  the  etiological  factors  active 
later  on. 

6.  Finally,  a  trauma  may  call  forth  a  psychosis  by  confine- 
ment in  bed,  by  the  continual  pains  which  it  occasions,  by  the 
insomnia,  the  loss  of  strength,  and,  with  the  laboring  population, 
the  worry  for  their  families  and  themselves,  especially  when 
coupled  with  a  faulty  existing  heredity  (consanguinity,  alcohol- 
ism, sj^philis). 

The  course,  duration,  and  results  of  the  psychosis  called 
forth  by  a  trauma  follow  the  clinical  type  which  it  portrays. 

Diagnosis.  The  confirmation  that  an  existing  psychosis  has 
been  conditioned  by  a  trauma  must  have  for  a  working  basis : 

1.  That  the  trauma  was  of  some  consequence.  It  is  of 
special  importance  to  ascertain  whether  the  trauma  which  was 
received  was  sufficient  to  produce  a  concussion  of  the  brain,  or 
only  a  psychical  shock. 

2.  That  nervous  phenomena  developed  contemporaneously 
with  the  injury.  This  proof  is  somewhat  difficult  at  times,  since 
the  insignificance  of  the  phenomena  does  not  allow  them  to  be 
clearly  recognized  at  once,  perhaps  not  at  all. 

Often  the  trauma  is  only  a  circumstance  which  lights  up  a 
latent  condition,  or  accelerates  the  course  of  a  disease  which  has 
been  imperfectly  present  for  some  time  (paranoiacs  consider  an 
accident  which  affects  them  as  brought  forth  by  inimical  powers 
which  persecute  them;  they  become  confirmed  in  this  belief  of 
the  existence  of  such  powers,  and  then  show  their  delusions 
plainly) .  Trauma  quite  often  lights  up  a  latent  or  slowly  develop- 
ing paresis  and  thereby  hastens  its  course. 

Finally,  trauma  is  quite  often  the  sequel  of  a  disease  of  the 
nervous  system  (attacks  of  vertigo,  carelessness  of  paretics,  diz- 
ziness and  falls  of  epileptics) . 

The  treatment  must  look  to  surger}',  where  there  are  scars 
of  the  skin  or  depressions  or  fractures  of  the  skull,  brain  ab- 
scesses, brain  tumors ;  for  the  rest,  the  special  type  of  the  disease 
must  be  treated  accordingly. 

To  the  traumatic  psychoses  also  belong  those  disturbances 
called  forth  by  sunstroke  and  heat  stroke^  under  the  type  of  rav- 


^  Regis.     Revue  neurologique,  1901. 


The  Traumatic  Psychoses:  Traumata.  281 


ing  excitement  willi  lialhicinations  and.  considerable  clouding 
of  the  consciousness;  tliese  often  begin  with  spasms  and  dilated 
reactionless  pupils,  may  end  in  recovery  witli  retrograde  amne- 
sia, but  sometimes  terminate  in  chronic  dementia  and  death. 

Finally,  here  belong  also  those  psychoses  which  have  been 
called  forth  by  operations  and  which  are  not  to  be  considered 
with  the  intoxication  psychoses  generated  by  medicated  bandages, 
like  the  iodoform  psychoses  for  instance. 

They  affect  predisposed  individuals,  whether  the  predisposi- 
tion is  from  hereditary  taint,  or  whether  they  are  from  the  dis- 
ease which  has  made  the  operation  necessary,  or  from  the  manner 
of  living  (alcohol),  or  from  remedies  (morphine,  chloral),  or, 
finally,  from  chagrin,  sorrow,  or  care. 

Operations  on  the  bladder,  castration,  making  an  anus  pre- 
ternaturalis,  operations  for  cataract,  appear  to  be  the  procedures 
especially  favorable  for  generating  psychoses  which  run  under 
the  type  of  delirium  hallucinatorium^  and  in  the  majority  of 
cases  break  out  on  the  second  to  fifth  day  after  the  operation. 


^  Picque.     Delire  psychiqvie   post-operatoire.     Annal.  med.   psycliol- 
ogiques,  July- August  and  Sept.-Oct.,  1898. 


Supplement. 


A.     GUIDE  FOR  THE  EXAMINATION  OF  ONE  MEN- 
TALLY DISEASED  AND  FOR  THE  PREPARA- 
TION OF  THE  CLINICAL  HISTORY. 

I.  The  patient  gives  the  answers,  which  must  be  finally 
corrected  or  completed  by  the  statements  of  witnesses  or 
relatives. 

1.  Name? 

.  "When  born? 
Occupation  ? 
Single  ? 
Married  ? 
Children? 
Their  age? 

2.  Life  history: 

"Where  and  with  what  results  did  you  attend  school? 

"Up  to  what  age  ? 

Special  talent? 

Description  of  beginning  and  further  course  of  occupation 

and  the  results? 
Its  change? 

Have  3'ou  been  a  soldier  ? 
Did  yon  suffer  any  disciplinary  punishment? 
(The  last  questions  are  often  important,  because  the  answers 
may  give  some  knowledge  of  the  somatic  and  mental  conditions 
then  existing) . 

(For  women). 
Appearance  of, the  first  menstruation?     Further  course, 

difficulties  attending  it  ? 
When  married  ? 
Pregnancies  and  parturitions? 
Xursed  your  children  yourself? 
(282) 


Guide  for  Examination.  283 

3.  Hereditary  basis : 

(a)   Father  or  mother  mentally  diseased  or  had  nervous 

disease  (epilepsy,  migraine)  ? 
Of  what  did  they  die  (apoplexy)  ? 
Were  they  blood  relations? 
(h)   Grandparents? 

(c)  Other  blood  relations? 
Children  ? 

(d)  Has  there  been  drunkenness  or  suicide  in  the  family? 

(e)  Are  certain  diseases  dominant  in  the  family  (tuber- 
culosis, diabetes,  cancer)  ? 

4.  What  diseases  have  3'ou  had  ? 
Normal  or  instrumental  birth? 

Inhibitions  of  development  (when  did  you  learn  to  speak, 

to  walk)  ? 
Diseases  of  childhood? 
Syphilis?     Its  course? 
Injuries  to  the  head? 
Accidents  in  general? 

5.  Nervous  diseases  from  which  you  have  suffered? 
Chorea  ? 

Pavor  nocturnus? 

Convulsions  ? 

Epileptic  seizures?     Their  course? 

Wetting  the  bed  ? 

States  of  unconsciousness  ? 

Hysterical  symptoms  ? 

Migraine  ? 

6.  Earlier  mental  disease? 

When?     Its  beginning,  course,  duration  and  result? 
Institution  treatment  ? 

7.  Conflicts  with  the  police  or  the  criminal  courts?     At- 

tempts at  suicide? 

8.  Habits? 

Excesses  in  Baccho,  venere  and  tobacco? 

Eeaction  to  alcohol? 

Onanism  ? 

Overexertion,  bodily  or  mental? 


28  Jt  Supplement. 

9.  "What  cause  is  given  for  the  present  disease? 

10.  "When  did  its  first  symptoms  appear  and  what  was  its 

course  ? 

Has  the  patient  made  attempts  at  suicide? 

Has  he  committed  punishable  actions? 

Has  he  endangered  himself  or  his  family  by  abnormal 
actions   (wasting  money,  excesses)  ? 

Of  what  does  the  patient  now  complain? 

(a)   psychicall}^ 

(&)  somatically? 

Fevers?  Epileptic  seizures  or  hysteric  attacks?  Appe- 
tite, bowels,  sleep? 

Menstruation  ? 

11,  Status  presens. 


(a)   Examination  of  the   Mental   Condition. 

From  the  preceding  examination  a  point  of  support  will 
often  be  found  as  to  the  presence  and  direction  of  delusions. 
In  this  case  one  should  make  use  of  the  remarks  of  the  patient 
and  connect  with  them  more  exact  information. 

This  confirmation  should  be  especially  directed  to  ascertain- 
ing whether  there  exist: — 

1.  Expansive  delusions  (over-estimation  of  himself,  meg- 
alomania). 

2.  Depressive  delusions  of  a  melancholic  nature  (delusion 
of  attention,  self -accusation,  the  delusion  of  transgression),  of 
a  hypochondric  nature  (complaints  of  sickness,  alteration  of 
the  organs,  the  disease  being  a  punishment  for  a  bad  life,  for  sins 
committed). 

3.  Paranoic  ideas  of  persecution  (the  patient  is  the  inno- 
cent victim  of  his  enemies,  a  conspiracy  exists  against  him) . 

4.  Combined  delusions  (delusion  of  persecution  and  meg- 
alomaniacal  ideas). 

5.  Systematized  delusions  (all  the  various  delusions  are 
brought  into  a  determined  system) . 

If  in  the  preceding  remarks  of  the  patient  there  is  no  point 
of  support  for  an  examination  on  the  delusions  present,  and  if  it 
is  not  clearly  ascertained  whether  he  is  completely  oriented  or 


Guide  for  Examination.  285 

not,  his  mental  condition  sliould  be  investigated  after  the  follow- 
ing form : 

(a)   Is  the  patient  oriented? 

(&)  What  is  his  conception  regarding  his  personality? 

(c)  What  has  he  observed  in  regard  to  his  mental  and 
physical  condition  ? 

(d)  What   remarks   does   he   make    about   the   external 
world  ? 

Questions  to  (a)  : — 

Where  are  you? 

Who  am  I  (the  examiner)  ? 

For  what  reason  are  3'ou  here? 

How  long  have  you  been  here? 

What  date  have  we? 
(It  will  appear  from  the  answers  to  these  questions  whether 
the  patient  is  oriented  or  disoriented). 
Questions  to   (6)  : — 

Your  present  calling? 

How  long  have  you  been  engaged  in  this? 

Do  you  wish  to  continue  it? 

Do  you  wish  to  take  up  another? 

Do  you  have  particular  plans  for  the  future? 

Have  you  now  another  preferred  position  ? 

Are  you  well-to-do? 

How  much  property  do  you  possess  ? 

Do  you  own  houses,  lands,  horses? 

Are  you  particularly  distinguished  in  any  special  line  ? 
Or: 

Can  you  follow  your  occupation  no  longer? 

Have  you  not  done  your  duty? 

Have  you  transgressed  in  any  way  ? 

Have  you  committed  a  crime? 

Are  you  tired  of  life? 
(The   answers   to    (h)    show   whether    the   personality    is 
changed  to  expansion  or  depression). 
Questions  to  (c)  : — 

Has  your  mind  or  body  altered  ? 

(a)   In  a  favorable  sense? 

Is  it  easy  for  vou  to  think? 


286  Supplement. 


Is  your  memory  good? 
Has  your  muscular  power  increased? 
Have  you  grown  heavier? 
Has  your  sexual  power  increased? 
Do  you  not  suffer  from  previous  physical  troubles? 
(h)   In  an  unfavorable  sense : — 
Has  your  memory  diminished? 
Is  any  mental  exertion  difficult  for  you? 
Are  5^our  bodily  organs  diseased?     Which? 
Do  you  feel  as  if  they  were  dead  ? 
Have  you  syphilis  ? 

Are  you  impotent  (hypochondric  ideas)  ? 
Questions  to  {d)  : — 

How  do  your  relatives  and  friends  behave  towards  you  ? 

Have  you  observed  that  people  wish  you  well? 

Have  you  many  friends? 

Any  lady  friends? 

Have  you  observed  that  people  pay  special  attention  to 

you? 
Have  you  noticed  any  peculiar  occurrences  on  the  street 
or  advertisements  in  the  journals  which  refer  to  your- 
self? 
Do  5^ou  consider  yourself  the  victim  of  persecutions? 
Who  are  the  persecutors? 
What  interest  do  they  have  in  injuring  you? 
Have  you  given  them  grounds  for  persecuting  you? 
Are  they  right  in  doing  this? 
Or  are  j'ou  innocent? 
Have  the  persecutors  any  personal  aims? 
Do  you  wish  to  prevent  them  from  attaining  their  object? 
In  single  cases  they  should  also  be  asked  how  the  external 
world  is  changed  and  whether  it  really  exists. 

Whether  the  ideas  expressed  are  to  be  regarded  as  delusions. 
If  delusions  are  present,  it  will  be  possible,  as  a  rule,  to  in- 
duce the  patient  to  speak  of  them.     Sometimes  this  only  suc- 
ceeds by  the  help  of  the  discovery  of  hallucinotions  present. 

One  should  not  ask,  "Do  you  hear  voices,"  "Do  you  see 
forms,"    for    in    such    cases    the    patients    are    frequently    re- 


Guide  for  Examination.  287 

served,  especially  if  they  are  repeatedly  asked  and  it  is  said  to 
them  that  the  phenomena  of  which  they  com2)lain  do  not  exist. 

One  should  proceed  systematically,  gradually. 

Do  you  have  roaring  in  the  head?  Noises  in  the  ears?  Do 
yon  sometimes  hear  noises  here  or  without  ?  At  night  ?  Are  not 
the  carpets  of  a  peculiar  color? 

Is  there  not  an  offensive  odor  sometimes?  Is  your  food 
sometimes  salty,  bitter,  or  sweet  ? 

Thus  one  learns  at  once  or  with  some  trouble  whether 
there  exist 

6.  Hallucinations  or  illusions  of  the  vision.  Description 
of  them : 

Stable  ?  Agitated  ?  Shadowy  ?  Shining  ?  Unilateral  ? 
Bilateral  with  different  contents? 

Does  the  patient  believe  in  their  objective  truth,  is  he  doubt- 
ful or  does  he  know  that  it  is  a  deception? 

7.  Hallucinations  or  illusions  of  audition.  Description 
of  them : 

One  person?     Men's,  women's,  children's  voices?     Aloud  or 
whispering?     Unilateral?     Bilateral  with  different  contents? 
Audibility  of  his  own  thoughts? 
In  regard  to  his  belief  in  their  reality? 

8.  Hallucinations  or  illusions  of  smell:  Repulsive? 
Agreeable  ? 

9.  Hallucinations  or  illusions  of  taste:  Eepulsive?  (Rot- 
ten? Carrion-like?  If  the  patient  complains  of  prick- 
ing, prickling,  on  the  tongue  at  eating,  it  should  be 
referred  to  hallucinations  of  the  gustatory  sense) ,  Agree- 
able? 

10.  Cutaneous  liallucinations  or  illusions: — 
Furring,  formication,  electricity  ? 

11.  Hallucinations  of  the  temperature  sense: — 
Having  a  hot  or  cold  sponge  passed  over  the  body  ? 

12.  Hallucinations  of  the  muscular  sense: — 

(a)   In  the  visual   apparatus?     (The  hallucinated   sees 
the  objects  small  or  large,  approaching  or  retreating. 
(h)   In  the  vocal  apparatus? 
Internal  speech? 


288  Supplement. 

13.  Kinesthetic  hallucinations: 

Does  the  patient  think  himself  moved  as  a  whole,  in 
single  members  ?  Does  he  feel  swaying  ?  Floating,  sink- 
ing, or  rising  in  air? 

14.  Hallucinations  of  the  ccenesthetic  sense: 

Does  he  feel  his  body,  his  heart,  or  other  organs  altered? 
In  what  condition  is  his  sesual  apparatus  ? 

One  should  never  be  satisfied  with  confirming  hallucinations 
in  one  or  another  sense,  but  should  examine  all  the  senses  accord- 
ing to  the  previous  form. 

If  one  has  ascertained  sense  deceptions,  he  should  ask  the 
patient  how  he  thinks  the  conspicuous  phenomena  occur,  since 
they  contradict  the  reality  and  established  physical  laws. 

If  he  says  that  they  are  called  forth  by  a  strange  power,  by 
enemies,  one  should  ask  what  interest  they  have  in  treating  him 
thus. 

This  examination  is  connected  with  the  discussion  of  the 
justification  by  the  jDatient  of  the  delusions  previously  established. 

From  the  answers  of  the  patient  previously  given  there  will 
now  be  points  of  departure  for  the  judgment  of  the  power  of 
reproduction  and  the  power  of  associations  (intelligence). 

The  more  exact  proof  follows  in  the  manner  to  be  spoken  of : 

15.  Power  of  reproduction.     2Iemory'. 

{a)   Pathologically  heightened   (hypermnesia)  ? 
(6)   Pathologically  depressed? 
The  questions  must  often  be  very  different,  according  to  the 
social  station  of  the  patient  and  his  education. 
Questions  from  the  multiplication  table? 
Xame  of  the  President?     Of  his  predecessor?     Of  the 

Governor  ? 
Continents?    States  of  the  Union? 
Elvers?     Months?     How  many  days  has  each? 
How  many  hours  in  a  day?     How  many  minutes  in  an 

hour? 
How  many  ten-cent  pieces  have  twenty  dollars?     How 

many  one  dollar? 
When  will  Christmas  come?     Your  birthday? 
The  events  of  the  dav  ? 


Guide  for  Examination.  289 

Is  your  memory  good  for  past  events,  poor  for  recent 

events  ? 
Narratives  of  your  youth? 
Who  visited  you  yesterday? 
What  happened  to-day? 

Do  you  have  loss  of  memory  for  certain  times  ? 
One  tests  the  power  of  attention  by  having  him  repeat  a 
number  or  a  sentence  after  a  short  time  or  immediately,  or  by 
showing  him  a  picture  and  explaining  it,  then,  shortly  aftervrard, 
asking  him  what  it  means. 

IG.  The  test  of  the  conditions  of  the  associations  must  as- 
certain whether   they  are   pathologically  heightened   or 
pathologically  depressed. 
The  first  is  shown  by  the  rapidity  of  the  answers,  by  the 
quick  transition  from  one  to  another. 

The  tests  as  to  whether  mental  wealmess  exists  must  regard, 
above  all,  the  education,  the  occupation,  the  social  position  of  the 
patient.  One  should  have  him  subtract,  divide,  compute  inter- 
est. Why  do  people  pay  taxes?  What  does  congress  signify? 
The  legislature?  One  should  ask  questions  connected  with  the 
occupation  of  the  patient  (with  merchants,  the  source  of  supply 
of  their  wares,  the  cost  of  replacing,  how  many  pounds  are  there 
in  a  kilogram,  how  much  is  a  meter  ?^) 

With  this  must  be  ascertained  whether  the  conception  of  the 
question  is  retarded,  whether  there  is  difficulty  in  understanding 
it  and  whether  the  answer  is  delayed  from  that  cause. 

17.  'Finally,  one  must  see  whether  determined  ideas  domi- 

nate the  thought,  or  whether  this  proceeds  according  to 
the  different  laws  of  association. 

18.  The  momentary  condition  of  the  mind — tlie  frame  of 

the  mind — must  be  noted.  One  must  observe  whether 
this  changes  often  during  the  examination  (see  emo- 
tions), whether  the  patient  shows  emotion  during  the 
examination,  especially  whether  he  shows  symptoms  of 


^  One  should  not  immediately  diagnose  "mental  weakness"  because 
one  or  more  answers  are  wrong,  especially  in  calculating.  Sometimes 
the  normal  persons  who  are  present,  his  wife,  son,  make  the  same  mis- 
take. 

19 


290  Supplement. 

anxiety  in  general  or  in  a  determined   direction,  es- 
peciall}^    if    there    is    also    hypochondric    anxiety    and 
precordial  anxiety. 
19.  The  fact,  which  is  to  he  taken  up  in  the  clinical  history, 
will  appear  from  the  examination,  whether  the  patient 
is  able  to  follow  its  course  attentively,  or  if  he  concen- 
trates his   attention  on  certain   delusions   and   sense- 
deceptions,  or  whether  his  capability  of  attention  is 
weakened. 
With  the  condition  of  the  attention  is  connected  the  greater 
or  less  susceptibility. 

(b)   Examination  of  the  Speech. 

Whether  there  are  neologisms? 
Whether  there  is  bradj-phrasia  ? 
Whether  there  is  logorrhoea? 
Whether  there  is  echo  speech? 
Whether  there  is  agrammatism? 
Whether  there  is  verbigeration  ? 
Whether  there  is  perseveration? 
Whether  'there  is  paraphrasia  ? 

Whether  there  is  dysarthritic  disturbance  of  the  speech 
(scanning,  bulbar  speech,  stuttering,  stammering)  ? 
One  should  then  have  the  patient  read  and  write,  and  note 
the  conclusions  of  this  examination. 

(c)   Examination  of  the  Body. 

1.  The  general  condition  of  nutrition: 
Condition  of  the  muscles?     Weight  of  the  body? 

2.  Expression  of  the  countenance  (maniacal,  depressive,  in- 

different, observing,  simple). 
Color  of  the  face  (pale,  cyanotic,  congested). 

3.  Cranium : 

Description  of  form  as  far  as  it  can  be  done  by  sight  or 
touch    (dolichocephalic,  brachycephalic.  microcephalic, 
hydrocephalic,  plagiocef)halic),  and  any  signs  of  degen- 
eration (ears,  eyes,  palate,  lips,  teeth). 
For  the  measurement  of  the  cranium  see,  1.  The  cranium 
and  the  so-called  physical  stigmata  of  degeneration. 


Guide  fur  Examination.  291 

Scars  on  the  scalp? 

4.  Eye  muscles,  especially  the  pupils:     Equal?  Contracted? 

Dilated?     Reflex  rigidity  of  the  pupils? 
Background   of   the   eye?     Eventual   examination   of   the 
field  of  vision   (epileptic,  hysteric,  alcoholic,  organic 
diseases  of  the  brain). 

5.  Peripheral  auditory  apparatus. 

6.  Olfactorius.     Trigeminus.     Facialis: 

Fibrillary  twitchings  of  the  face  muscles,  asymmetry  of 
the  face?  Glossopharyngeus  (laryngeal  reflex)  ?  Deg- 
lutition? Accessorius  (paralysis  of  the  vocal 
chords)  ?  Hypoglossiis  (trembling  of  the  tongue), 
fibrillary  twitchings,  tongne  protruded  straight  or  ob- 
liquely) ? 

7.  Upper  and  lower  extremities.     The  trunk. 

Stature?     Distortions?     Signs  of  degeneration?     Gait? 

Tension  of  the  muscles?  (Passive  movements  in  the  ar- 
ticulations. One  must  examine  whether  there  is  an 
equal  tension  of  all  the  muscles,  as  in  contractures,  or 
if  the  tension  is  solely  in  the  antagonists,  which  appears 
in  the  movements  of  muscles  entering  into  activity 
(negativism,  arbitrary  tension)  ;  further,  whether 
the  members  remain  still  in  the  position  brought  about 
passively) . 

Spontaneous  movements?     Stereotypes? 

Choreic  movements  ?    Tics  ? 

Pareses  ?     Paralyses  ?     Tremors  ? 

Muscular  atrophy?     Eventual  electric  examination? 

Eeflexes  ? 

Tendon  reflexes  (patellar,  tendoi^  of  Achilles,  cubital). 

Ankle  clonus? 

Cutaneous  reflexes? 

Babinski's  reflex? 

8.  Sensorial  cutaneous  nerves? 
Hyperesthesias?     Anesthesias?     Paresthesias? 
Feeling  of  pain  ?     Sense  of  temperature  ? 

9.  Vasomotor  and  trophic  nerves? 

Condition  of  the  cutis  (pale,  blue).  Hair.  Saliva.  Per- 
spiration.    Tears.     Decubitus. 


292  Supplement. 


10.  Discharge  of  urine  and  feces : 

Enuresis.  Dysuria.  Ischuria  paracloxa.  Constipation. 
Involuntary  discharges. 

11.  Organs  of  digestion. 

Scars  on  the  tongue?     Other  peculiarities? 
Stomach  ?     Liver  ?     Spleen  ? 

12.  Organs  of  respiration: 
Larynx  ?     Lungs  ? 

13.  Circulatory  apparatus'. 

Heart?  Pulse?  Atheroma  of  the  arterial  s)^stem? 
(Eaclial  pulse?  Serpentine  temporal  arteries?  Caro- 
tid arteries?)  Number  of  pvilse  beats  and  their  con- 
dition ? 

14.  Examination  of  the  urine  (especially  for  albumin,  in- 

dican,  and  sugar). 

15.  Sexual  apparatus: 
Signs  of  degeneration? 

In  women,  eventually  manual  examination. 

If  there  are  positive  abnormal  actions,  which  finally  deter- 
mine the  calling  in  of  a  consultant,  or  committing  the  patient 
to  an  institution,  one  should  ask  the  patient,  after  the  end  of 
the  examination,  what  he  thinks  of  such  actions,  why  he  per- 
formed them,  whether  he  denies  them,  or  if  he  considers  them 
justified.  Accordingl}^  his  ethical,  religious,  and  esthetic  feel- 
ings will  appear. 

At  the  end  one  should  explain  to  the  patient  that  he  is  sick, 
that  he  will  recover  rapidly  if  he  obeys  implicitly  all  the  orders 
of  the  physician. 

The  diagnosis  forms  the  conclusion  of  the  clinical  history. 

In  many  forms  of  disease  a  momentary  diagnosis  will  be 
possible:  High  grade  of  idiotism,  hebephrenia  with  following 
dementia  prgecox,  myxedema,  paresis  (the  patient  comes  into  the 
room  with  a  "good  morning"  pronounced  paralytically,  an  idiotic 
expression  of  the  countenance,  and  a  spastic-paretic  or  atactic 
gait). 

The  beginner  will  reach  a  decision  as  to  the  form  of  the 
disease  most  surely  by  the  way  of  differential  diagnosis. 

It  may  be  decided  from  the  anamnesia  whether  a  mental 
pathological  state  existed  from  childhood  up   (idiotism).     The 


Guide  for  Examination.  293 


diagnosis  will  be  confirmed   by  the  existing  mental  weakness, 
hydrocephalus,  microccphalus,  paralyses. 

If  this  is  excluded  there  would  be  a  mental  disease  ac- 
quired later;  thus  the  first  question  would  be  whether  an  organi- 
cally conditioned  psychosis  is  present  or  not. 

For  the  first,  the  presence  of  paralyses  of  the  motility,  reflex 
rigidity  of  the  pupils,  loss  of  the  patellar  reflexes,  paralytic  dis- 
turbance of  speech  would  decide. 

The  next  thing  to  investigate  is  whether  there  is  paresis, 
senile  dementia,  syphilitic  disease,  focal  diseases. 
For  the  differential  diagnosis,  see  Paresis. 
If  an  organic  psychosis  is  excluded,  one  should  consider  an 
intoxication  psychosis.  Here  the  anamnesia  will  be  decisive; 
as  to  alcoholism,  see  delirium  tremens,  subacute  alcoholic 
psychoses. 

•Epileptic  and  hysteric  psychoses  are  at  once  identified  by 
the  epileptic  seizures  and  hysteric  attacks  shown  in  the  anam- 
nesia, as  well  as  by  the  epileptic  seizures  and  hysteric  attacks 
during  the  psychosis.  If  all  these  forms  of  psychic  disturbance 
are  excluded,  the  diagnosis  is  that  of  a  functional  psychosis. 

That  of  delirium  hallucinatorium  is  characterized  by  the 
great  obscurity  of  the  consciousness ;  that  of  mania,  by  the  accel- 
erated efflux  of  ideas;  that  of  melancholia,  by  the  depressed 
frame  of  mind  and  inhibition;  that  of  paranoia,  by  the  sys- 
tematized delusions ;  and  that  of  acute  dementia,  by  the  mental 
paralysis.  The  diagnosis  of  circular  psychosis  can  be  determined 
with  certainty  only  by  the  course. 

There  may  be  difficulties  with  the  diagnosis  even  here,  if 
the  functional  psychosis  has  ended  in  a  condition  of  dementia. 

The  anamnesia  decides  that  and  the  type  of  terminal  demen- 
tia, as  it  has  been  described. 

In  order  to  reach  a  diagnosis  one  should  examine  along  a 
constant,  essential  symptom,  and  ask  himself  in  what  forms 
that  symptom  is  characteristic,  and  by  the  exclusion  of  the  rest 
come  to  the  type  of  psychosis. 

The  patient  shows,  (3.,g..  permanent,  prominent  megalonumia. 
Then  the  diagnosis  is  cither:  1,  paresis;  2,  paranoia;  3,  mania; 
.4,  alcoholic,  or,  5,  epileptic  psychosis;  6,  maniacal  stage  of  cir- 
cular psychosis. 


294  Supplement. 


By  means  of  the  anamnesia  and  by  regarding  the  pathological 
symi^toms  present,  except  megalomania,  from  the  side  of  the 
psyche  {e.g.,  mental  weakness)  and  the  body  {e.g.,  paralytic 
phenomena),  one  may  reach  the  true  diagnosis. 

II.  The  Patient  Talks,  but  His  Statements  Are  Confused. 

The  anamnesia  must  then  be  gathered  from  witnesses  or 
from  the  statements  of  relatives. 

The  manner  in  which  the  patient  answers  the  questions  must 
be  noted  in  the  examination. 

It  must  be  ascertained : 

1.  Whether  delusions  or  hallucinations  are  shown  by  the 

confused  speech,  or  whether  the  presence  of  hallu- 
cinations is  possible  from  the  movements  or  appearance 
of  the  patient. 

2.  The  attempt  should  be  made  to  guide  and  fix  him  in  pass- 

ing on  some  questions  which  essentially  require  only 
the  power  of  reproduction.  Whether  the  patient  can 
be  guided  or  not,  is  to  be  noted.    Further, 

3.  Whether  his  speech  shows  any  of  the  above-designated 

disturbances. 

4.  Whether  his  frame  of  mind  is  serene,  depressed,  or  in- 

different. 

A  careful  physical  examination  should  then  be  made. 

The  essential  question  here  is  to  ascertain  whether  there  is 
a  hallucinatory,  maniacal,  or  demented  form  of  confusion. 

A  paraphasic  confusion  should  also  be  considered.  In  re- 
gard to  the  special  diagnosis,  see  confusion,  attention. 

III.  The  Patient  is  in  a  Stuporous  Condition. 

One  should  describe  exactly  how  the  patient  lies,  stands,  or 
sits,  whether  he  is  agitated,  and  whether  these  movements  are 
impulsive  or  stereotyped  actions. 

Further,  the  reaction  to  external  stimuli  is  to  be  tested,  how 
he  behaves  when  questions  are  asked,  how  he  takes  nourishment, 
whether  there  is  flexibilitas  cerea. 

The  somatic  examination  must  be  made  carefully,  the  be- 
havior of  the  motor  apparatus    (hypertonia,  katatonia,  hypo- 


Commitment  to  an  Institution.  295 

tonia),  the  reflexes   (tendon,  cutaneous,  and  visceral),  and  tlie 
sensibility  must  be  tested. 

For  a  guide  to  the  special  diagnosis,  see  stupor. 


IV.  The  Patient  is  Raving. 

Here,  in  the  impossibility  of  examination,  the  maniacal  ac- 
tions and  the  behavior  of  the  patient  are  to  be  described. 

The  expression  of  the  countenance  is  to  be  observed,  and  the 
possibility  of  turning  the  attention  of  the  patient  for  a  short 
time. 

For  the  description  of  the  condition  and  the  diagnosis,  see 
raving. 

V.  The  Patient  Does  Not  Speak,  Although  He  is 
Not  Stuporous. 

The  examination  is  the  same  as  with  the  stuporous. 
The  diagnosis  must  consider  the  disturbances  of  speech. 


B.     COMMITMENT   OF  A  PATIENT  TO  AN  INSTITU- 
TION FOR  THE  INSANE. 

In  the  year  1889,  the  State  of  New  York  created  a  State 
supervision  over  the  insane,  and  vested  full  authority  in  a  com- 
mission known  as  the  State  commission  in  lunacy.  The  com- 
mission has  adopted  a  uniform  commital  blank,  to  be  used  in  all 
State  and  private  institutions  under  their  supervision.  The 
State  hospitals  are  located  at  Utica,  Willard,  Poughkeepsie,  Mid- 
dletown,  Buffalo,  Binghamton,  Ogdensburg,  Bochester,  Kings 
Park,  Brooklyn,  Ward's  Island,  Central  Islip,  Gowanda,  Mattea- 
wan,  and  Dannemora.  Private  institutions  caring  for  the  insane 
are  scattered  throughout  the  State,  and  are  licensed  by  and  under 
the  supervision  of  the  State  commission. 

For  convenience  of  reference  sections  60,  61,  63,  63,  and  64 
of  article  3  of  the  insanity  law,  constituting  chapter  28  of  the 
general  laws,  as  enacted  by  chapter  545  of  the  laws  of  1896,  being 
the  principal  sections  relating  to  the  commitment  of  the  insane, 
are  here  inserted : 


296  Supplement. 


Section  60.  Order  for  commitment  of  an  insane  person. — A  person 
alleged  to  be  insane  and  who  is  not  in  confinement  on  a  criminal  charge, 
may  be  committed  to  and  confined  in  an  institution  for  the  custody  and 
treatment  of  the  insane,  upon  an  order  made  by  a  judge  of  a  court  of 
record  of  the  city  or  county,  or  a  justice  of  the  supreme  court  of  the 
judical  district,  in  which  the  alleged  insane  person  resides  or  may  be, 
adjudging  such  person  to  be  insane,  upon  a  certificate  of  lunacy  male 
by  two  qualified  medical  examiners  in  lunacy,  accompanied  by  a  verified 
petition  therefor,  or  upon  such  certificate'  and  petition,  and  after  a 
hearing  to  determine  such  question,  as  provided  in  this  article.  The 
commission  shall  prescribe  and  furnish  blanks  for  such  certificates  and 
petitions,  which  shall  be  made  only  upon  such  blanks.  An  insane  person 
shall  be  committed  only  to  a  State  hospital,  a  duly  licensed  institution 
for  the  insane,  or  the  Matteawan  State  Hospital,  or  to  the  care  and 
custody  of  a  relative  or  committee,  as  hereinafter  provided.  No  idiot 
shall  be  committed  to  or  confined  in  a  State  hospital.  But  any  epileptic 
or  feeble-minded  jaerson  becoming  insane  may  be  committed  as  an  insane 
person  to  a  State  hospital  for  custody  and  treatment  therein. 

Skc.  61.  Medical  examiners  in  lunacy;  certificates  of  lunacy. — The 
certificate  of  lunacy  must  show  that  such  person  is  insane  and  must  be 
made  by  two  reputable  physicians,  graduates  of  an  incoi"porated  medical 
college,  who  have  been  in  the  actual  practice  of  their  profession  at  least 
three  years,  and  have  filed  with  the  commission  a  certified  copy  of  the 
certificate  of  a  judge  of  a  court  of  record,  showing  such  qualifications  in 
accordance  with  forms  prescribed  by  the  commission. 

Such  physicians  shall  jointly  make  a  final  examination  of  the  person 
alleged  to  be  insane  within  ten  days  next  before  the  granting  of  the 
order.  The  date  of  the  certificate  of  lunacy  shall  be  the  date  of  such 
joint  examination.  Such  certificate  of  lunacy  shall  be  in  the  form  pr^?- 
scribed  by  the  commission,  and  shall  contain  the  facts  and  circumstances 
vipon  which  the  judgment  of  the  physicians  is  based  and  show  that  the 
condition  of  the  person  examined  is  such  as  to  require  care  and  treat- 
ment in  an  institution  for  the  care,  custody  and  treatment  of  the  insane. 

Neither  of  such  physicians  shall  be  a  relative  of  the  persons  apply- 
ing for  the  order  or  of  the  person  alleged  to  be  insane,  or  a  manager, 
superintendent,  proprietor,  ofificer,  stockholder,  or  have  any  pecuniary 
interest,  directly  or  indirectly,  or  be  an  attending  physician  in  the  in- 
stitution to  which  it  is  proposed  to  commit  such  person. 

Sec.  62.  Proceedings  to  detenu ine  the  question  of  insanity. — Any 
person  with  whom  an  alleged  insane  i>erson  may  reside  or  at  whose  house 
he  may  be,  or  the  father  or  mother,  husband  or  wife,  brother  or  sister, 
or  the  child  of  any  such  person,  and  any  overseer  of  the  poor  of  the  town, 
and  superintendent  of  the  poor  of  the  county  in  which  any  such  person 
may  be,  may  apply  for  such  order,  by  presenting  a  verified  petition  con- 
taining a  statement  of  the  facts  upon  which  the  allegation  of  insanity  is 
based,  and  because  of  which  the  application  for  the  order  is  made.    Such 


Laws  Relating  to  Commitment  of  the  Insane.  297 


petition  shall  be  accompanied  by  the  certificate  of  lunacy  of  the  medical 
examiners,  as  prescribed  in  the  preceding  section.  Notice  of  such  appli- 
cation shall  be  served  i>ersonally,  at  least  one  day  before  making  such 
application,  upon  the  person  alleged  to  be  insane,  and  if  made  by  an 
overseer  or  superintendent  of  the  poor,  also  ujjon  the  husband  or  wife, 
father  or  mother  or  next  of  kin  of  such  alleged  insane  person,  if  there 
be  any  such  known  to  be  residing  within  the  count}',  and  if  not,  upon  the 
person  with  wliom  such  alleged  insane  person  may  reside,  or  at  whose 
liouse  he  may  be.  The  judge  to  whom  the  application  is  to  be  made  may 
dispense  with  such  personal  service,  or  may  direct  substituted  service 
to  be  made  upon  some  person  to  be  designated  by  him.  He  shall  state  in 
a  certilieate  to  be  attached  to  the  petition  his  reason  for  dispensing  with 
personal  service  of  such  notice,  and  if  substituted  service  is  directed, 
the  name  of  the  person  to  be  served  therewith. 

Tlie  judge  to  whom  such  application  is  made  may,  if  no  demand  is 
made  for  a  hearing  in  behalf  of  the  alleged  insane  person,  proceed  forth- 
with to  determine  the  question  of  insanity,  and  if  satisfied  that  the 
alleged  insane  person  is  insane,  may  immediately  issue  an  order  for  the 
commitment  of  such  person  to  an  institution  for  the  custody  and  treat- 
ment of  the  insane.  If,  however,  it  appears  that  such  insane  person  is 
hannless  and  his  relatives  or  a  committee  of  his  person  are  willing  and 
able  to  properly  care  for  him,  at  some  place  other  than  such  institution, 
upon  their  written  consent,  the  judge  may  order  that  he  be  placed  in  the 
care  and  custody  of  such  relatives  or  such  committee.  Such  judge  may, 
in  his  discretion,  require  other  proofs  in  addition  to  the  petition  and 
certificate  of  the  medical  examiners. 

Upon  the  demand  of  any  relative  or  near  friend  in  behalf  of  such 
alleged  insane  person,  the  judge  shall^  or  he  may  upon  his  own  motion, 
issue  an  order  directing  the  hearing  of  such  application  before  him  at  a 
time  not  more  than  five  days  from  the  date  of  such  order,  which  shall 
be  served  upon  the  parties  interested  in  the  application  and  upon  such 
other  persons  as  the  judge,  in  his  discretion,  may  name.  Upon  such  day, 
or  upon  such  other  day  to  which  the  proceeding  shall  be  regularly  ad- 
journed, he  shall  hear  the  testimony  introduced  by  the  parties  and 
examine  the  alleged  insane  person  if  deemed  advisable  in  or  out  of  court 
and  render  a  decision  in  writing  as  to  such  person's  insanity.  If  it  be 
determined  that  such  person  is  insane,  the  judge  shall  forthwith  issue 
liis  order  committing  him  to  an  institution  for  the  custody  and  treat- 
ment of  the  insane,  or  make  such  other  order  as  is  provided  in  this 
section.  If  such  judge  can  not  hear  the  application  he  may,  in  his  order 
directing  the  hearing,  name  some  referee,  who  shall  hear  the  testimony 
and  report  the  same  forthwith,  with  his  opinion  thereon,  to  such  judge, 
who  shall,  if  satisfied  with  such  report,  render  his  de?ision  accordingly. 
.  If  the  commitment  be  made  to  a  State  hospital,  the  order  shall  be  ac- 
companied by  a  Avritten  statement  of  the  judge  as  to  the  financial  con- 
dition of  the  insane  person  and  of  the  persons  legally  liable  for  his 
maintenance  as  far  as  can  be  ascertained.     The  superintendent  of  such 


298  Supplement. 

State  hospital  shall  be  inimediately  notified  of  such  commitment,  and  he 
shall,  at  once,  make  provisions  for  the  transfer  of  such  insane  person 
to  such  hospital. 

The  petition  of  the  applicant,  the  certificate  in  lunacy  of  the  med- 
ical examiners,  the  order  directing  a  further  hearing  as  provided  in  this 
section,  if  one  be  issued,  and  the  decision  of  the  judge  or  referee  and 
the  order  of  commitment  shall  be  presented  at  the  time  of  the  commit- 
ment to  the  suj)erintendent  or  person  in  charge  of  the  institution  to 
which  the  insane  person  is  contmitted,  and  verbatim  copies  shall  be  for- 
^^arded  by  such  superintendent  or  person  in  charge  and  filed  in  the 
office  of  the  State  commission  in  lunacy.  The  relative,  or  committee  to 
whose  care  and  custody  any  insane  person  is  committed,  shall  forthwith 
file  the  petition,  certificate  and  order,  in  the  office  of  the  clerk  of  the 
county  where  such  order  is  made,  and  transmit  a  certified  copy  of  such 
papers,  to  the  commission  in  lunacy,  and  procure  and  retain  another  such 
certified  copy. 

The  superintendent  or  person  in  charge  of  any  institution  for  the 
care  and  treatment  of  the  insane  may  refuse  to  receive  any  person  upon 
any  such  order,  if  the  papers  required  to  be  presented  shall  not  comply 
with  the  provisions  of  this  section,  or  if  in  his  judgment,  such  person  is 
not  insane  within  the  meaning  of  this  statute,  or  if  received,  such  person 
may  be  discharged  by  the  commission.  Xo  person  shall  be  admitted  to 
any  such  institution  under  such  order  after  the  expiration  of  five  days 
from  and  inclusive  of  the  date  thereof.  Notwithstanding  the  requii-e- 
ments  of  this  section  that  an  alleged  insane  person  be  duly  committed 
by  an  order  of  the  court,  in  a  ease  where  the  condition  of  such  person 
is  such  that  it  would  be  for  his  benefit  to  receive  immediate  care  and 
treatment,  or  if  he  is  dangerously  insane  so  as  to  render  it  necessary 
for  public  safety  that  he  be  immediately  confined,  he  shall  be  forthwith 
received  by  a  State  institution  authorized  by  law  to  care  for  the  insane. 
In  such  case  such  insane  person  shall  be  so  received  by  such  institution 
upon  a  certificate  of  lunacy,  executed  by  two  medical  examiners  in  lunacy 
after  the  examination  and  in  the  manner  provided  in  the  preceding 
section,  and  upon  a  petition  made  by  the  person  authorized  by  this  sec- 
tion to  apply  to  a  court  for  an  order  of  commitment.  By  virtue  of  such 
certificate  of  lunacy  and  such  petition  such  insane  person  may  be  re- 
tained in  such  institution  for  a  period  not  to  exceed  five  days.  Prior 
to  the  expiration  of  such  time  an  order  for  his  commitment  must  be 
obtained  in  the  manner  provided  by  this  section.  The  certificate  of 
limacy  executed  by  such  physicians  must  contain  adequate  reasons  why 
the  insane  person  should  be  immediately  received  in  an  institution  for 
the  insane  for  treatment.  The  superintendent  or  person  in  charge  of  any 
such  institution  may  refuse  to  receive  such  insane  person  upon  such 
certificate  and  petition,  if  in  his  judginent  the  reasons  stated  in  the 
certificate,  or  the  condition  of  the  patient,  are  not  sufficient,  or  is  not 
of  such  character,  as  to  make  it  necessary  that  the  patient  should  receive 
immediate  treatment.     (As  amended  by  ch.  146,  L.  1903.) 


Laws  Relating  to  Commitment  of  the  Insane.  299 


Sec.  G3.  Appeal  from  order  of  commitment. — If  a  person  ordered 
to  be  committed,  pursuant  to  this  chapter,  or  any  friend  in  liis  behalf, 
is  dissatisfied  with  the  final  order  of  a  judge  or  justice  committing  him 
he  may,  within  ten  days  after  the  making  of  sucli  order  appeal  therefrom 
to  a  justice  of  the  supreme  coiu't  other  than  the  justice  making  the  order, 
wlio  shall  cause  a  jury  to  be  summoned  as  in  case  of  proceedings  for  the 
appointment  of  a  conrmittee  for  an  insane  person,  and  shall  try  the  (lucs- 
tion  of  such  insanity  in  the  same  manner  as  in  proceedings  for  the 
appointment  of  a  committee.  Before  such  appeal  shall  be  lieard,  ;^ueh 
person  shall  make  a  deposit  or  give  a  bond,  to  be  approved  by  a  justice 
of  the  supreme  court,  for  the  payment  of  the  costs  of  the  appeal,  if  tlie 
order  of  conunitment  is  sustained.  If  the  verdict  of  the  jury  be  that 
such  person  is  insane,-  the  justice  shall  certify  that  fact  and  make  an 
order  of  commitment  as  upon  the  original  hearing.  Such  order  shall  be 
presented,  at  the  time  of  the  commitment  of  such  insane  person,  to  the 
superintendent  or  person  in  charge  of  the  institution  to  which  the  insane 
person  is  committed  and  a  copy  thereof  shall  be  forwarded  to  the  com- 
mission by  such  superintendent  or  person  in  charge  and  filed  in  the 
office  thereof.  Proceedings  mider  the  order  shall  not  be  stayed  pending 
an  appeal  therefrom,  except  upon  an  order  of  a  justice  of  the  supreme 
court,  and  made  upon  a  notice  and  after  a  hearing,  with  provisions  made 
therein  for  such  temj^orary  care  or  confinement  of  the  alleged  insane 
person  as  may  be  deemed  necessary. 

If  a  judge  shall  refuse  to  gi'ant  an  application  for  an  order  of  com- 
mitment of  an  insane  person  proved  to  be  dangerous  to  himself  or  others, 
if  at  large,  he  shall  state  his  reasons  for  such  refusal  in  writing,  and 
any  person  aggTieved  thereby  may  appeal  therefrom  in  the  same  manner 
and  under  like  conditions  as  from  an  order  of  commitment. 

Sec.  64.  Costs  of  commitnient. — The  costs  necessarily  incurred  in 
determining  the  question  of  the  insanity  of  a  poor  or  indigent  person 
and  in  securing  his  admission  into  a  State  hospital,  and  the  expense  of 
providing  proper  clothing  for  such  person,  in  accordance  with  the  rules 
and  regulations  adopted  by  the  comanission,  shall  be  a  charge  upon  the 
town,  city  or  county  securing  the  conunitment.  Such  costs  shall  include 
the  fees  allowed  by  the  judge  or  justice  ordering  the  commitment  to  the 
medical  examiners.  If  the  person  sought  to  be  committed  is  not  a 
jjoor  or  indigent  person,  the  costs  of  the  proceedings  to  determine  his 
insanity  and  to  secure  his  commitment,  as  provided  in  this  article,  shall 
be  a  charge  upon  his  estate,  or  shall  be  paid  by  the  persons  legally 
liable  for  his  maintenance.  If  in  such  proceedings,  the  alleged  insane 
person  is  determined  not  to  be  insane,  the  judge  or  justice  may,  in  his 
discretion,  charge  the  costs  of  the  proceedings  to  the  person  making 
the  application  for  an  order  of  commitment,  and  judgment  may  be 
entered  for  the  amount  thereof  and  enforced  by  execution  against  such 
persons. 


500  Supplement. 


The  following  blank  sliould  be  filled  out  only  by  two  medical 
examiners  qualified  according  to  section  60 : — 

Certificate  of  Lunacy 

State  of  Xew  York, 

County  of J>ss: 

City,  Town  or  Village 


Statement  of  Facts. 


1.  Patient  resides  at ,  county  of ; 

age years;    nativity  (if  foreign,  how  long  in  U.  S.J ; 

sex :    color ;    occupation ;    single, 

maiTied,  widowed,  divorced.    (Strike  out  words  not  required.) 

2.  Birthplace  of  father ;    of  mother 

3.  Xumber  of  previous  attacks.  . .  . ;    present  attack  began 190 

(If  the  patient  has  ever  been  an  inmate  of  an  institution  for  the  insane, 
state  when  and  where,  and  whether  discharged  recovered  or  otherwise.] 

4.  Was  the  present  attack  gi-adual  or  rapid  in  its  onset  ? 

5.  '\^Tiat  is  the  patient's  general  physical  condition? 

(If  afflicted  irith  any  iufinnitu  or  disease  other  than  insanity,  state  it.) . . 

6.  Is  the  patient  cleanly  or  uncleanly  in  personal  habits  ? 

7.  Is   the  patient  violent,   dangerous,   destructive,    excited    or   de 

pressed,  homicidal  or  suicidal  ? 

(If  either  homicide  or  suicide  has  been  attempted  or  threatened,  it  should 
be  so  stated.) 

8.  WTaat  is  the  supposed  cause  of  the  insanity?  (State  both  predis- 
posing and  exciting  causes,  if  known.) 

9.  Has  the  patient  insane  relatives?  If  so,  state  the  degree  of 
consanguinity,  and  whether  paternal  or  maternal 

10.  State  the  patient's  habits  as  to  the  use  of  liquor,  tobacco,  opium 
or  other  di-ug,  and  whether  excessive  or  moderate 

We, ,  a  legal  resident  of 

,  county  of ,  State  of  Xew  York,  and 

,  a   legal   resident   of 

,  county  of and  State  aforesaid, 

being  severally  and  duly  sworn,  do  severally  certify  and  each  for  himself 
certifies,  with  the  exceptions  which  are  hereinafter  noted,  as  follows: 

1.  I  am  a  graduate  of  an  incorporated  medical  college,  and  a  quali- 
fied medical  examiner  in  lunacy;  a  certificate  of  my  qualifications  as  such 


Form  of  Commiital.  301 

examiner,  or  certified  copy  thereof,  is  on  iile  in  the  ollice  of  tlie  State 
Commission  in  Lunacy,  and  I  have  received  from  its  secretary  an  acknowl- 
edgment of  the  receipt  of  the  same. 

2.  I  have  with  care  and  diligence  personally  observed  and  examined 

Oil  the  date  of  this  certificate,  namely,  on  the day  of ,  190    , 

,  now  residing  or  being  at 

in  the  county  of ,  and  as  a  result  of  such  joint  examination 

find,  and  hereby  certify  to  the  fact,  that  he  is  insane  and  a  proper  sub- 
ject for  custody  and  treatment  in  some  institution  for  the  insane,  as  an 
insane  person  under  the  provisions  of  the  statute. 

3.  I  have  formed  the  above  opinion  upon  the  subjoined  facts: 

a.  Facts  indicating  insanity  personally  observed  by  me,  as  follows: 
The  patient  said  (State  what  the  patient  said,  if  anything,  in  pres- 
ence of  the  examiners) : 


The  patient  (State  ivhat  the  patient  did  in  presence  of  the  examiners 
and  also  describe  his  or  her  appearance  and  manner): 


b.  Other  facts  indicating  insanity,  including  those  communicated  to 
me  by  others,  as  follows:  (State  what,  if  any,  significant  change  there 
has  been  in  the  patient's  disposition,  mental  condition,  business  or  social 
liabits,  or  bitdily  health.) 


4.  That  the  facts  stated  and  information  contained  in  this  certificate 
are  true  to  the  best  of  my  knowledge  and  belief. 

,  M.D. 

,  M.D. 


Severally  subscribed  and  swora  to  before  me  this. . 
day  of ,  190 


302  Supplement. 


The  statutes  of  the  different  States  and  Territories  of  the 
United  States  vary  materially  in  regard  to  the  form  of  procedure 
necessary  to  commit  a  patient  to  an  institution  for  the  insane. 
These  hare  been  abstracted  by  Dr.  Henry  Putnam  Stearns,  and 
may  be  found  in  the  appendix  of  his  lectures  on  Mental  Diseases. 


INDEX. 


Absinthism,  249. 

Abstinence,     plienomena     in     mor- 
phinists. 247. 
Abulia,  40. 

Acetone  in  expired  air.  111. 
Acetonuria,  230. 
Achilles  tendon  reflex,  105. 
Actions,  arbitrary,  72,  70. 

disturbances,   70. 

emotional,  58,  71. 

instinctive,  71. 

of  the  imbecile,  165,  166. 
Afl:ections,  pathological,  55. 
Agoraphobia,  56. 
Agrammatism,  80. 
Agrypnia,  61. 
Aidoiomonomania,  54. 
Akataphasia,  80,  169. 
Akinesis,  73. 
Alcoholic  psychoses,  234. 

psychosis,  acute,  235. 
subacute,  236. 

pseudo-paresis,  243. 
Alcoholism,  chronic,  242. 

results  of,  244. 
Alliteration,  184. 
Alogia,  77,  169. 
Alo])ecia  areata,  109. 
Ambidexterity,  170. 
Amnions  horn,  218. 
Amnesia,  43,   76. 

general,  44. 

partial,  44. 

retroactive    or     retrograde,     45, 
177. 

senile,  44. 
Amyl  hydrate,  156. 
Anarthritic  deafness,   78. 
Anarthrie  idiots,  169. 
Anergic  stupor,  67. 
Angioparalytic  states,  107. 
Angiospastic  conditions,  106. 
Angle,  facial,  87. 
Aiigophrasia,  79. 
Anorexia,  48. 

Antagonistic  hallucination,   17. 
Anthropophagi,  48. 
Antipyrin,  107,   154. 
Antisocial,  166. 
Anxiety,  55,  154. 

precordial,  106. 

psychoses  of,  55. 


Aphasia,  78,   169,  275. 
Aphasic  confusion,  270. 
Apoplectiform  attacks,  260. 
Apoplexy,  275. 
Aprosexia,  60,   162,   170. 
Arc,  frontal,  91. 
Argyll-Robertson  pupil,  100. 
Arithmomania,   199. 
Arsenic,  203. 

Arteriosclerotic   psj'choses,   272. 
Asphyxia,  local,  106. 
Associations,   heightening  of   their 
rapiditj',  26. 

laws  of,  2. 

their  diminution,  39,  163. 

time  of,  crude,  20. 
Assonance,  184. 

Atropin,  154,  187,  199,  218,  241. 
Attention,  4,  00,  238. 

delusion,  30. 

mania,  29. 
Audibility  of  thought,    11. 
Auto-intoxication,  130. 

psychoses,   225,  230. 

Babinski's  reflex,  105,  259. 
Basedow's  disease,  94,  .229. 
Baths,  protracted,  155. 
Belching,   111. 
Betrothed,  193. 
Blainville's  ear,  94. 
Blood,  composition  of,  110. 

pressure,   110. 

sweating,  107. 

vomiting,   107. 
Braehyeephalic,  86. 
Brachycephalus,  90. 
Bradyphrasia,  80. 
Brain  hypertrophy,  tuberous,  172. 

sclerosis,  172. 

tumors,  psychoses,  276. 

weight,  145,  172. 
Bright's  disease,  239. 
Bromide,  107. 

intoxication,  249. 

•preparations,  154,  217. 
Bulimia,  111. 

Cachexia,  pachydermic,  227. 
Caffeino-natrium-salicylicum.     157. 

247. 
Cannabism,  249. 

(303) 


304 


Index. 


rcTiTOes 


Carbonic  acid  gas  psyclWSes,  249. 
Carbon  oxide  intoxication,  249. 
Carcinoma,  230. 

Cardiac    diseases    as   cause    of    in- 
sanity, 130. 
Cams,  67. 
Catalepsy,  65. 
Census    of    the    insane    in    Canton 

Zurich,  113. 
Census  of  the  insane  in  England. 

113. 
Census  of  the  insane  in  New  York, 

113. 
Census  of   the   insane   in   Prussia, 

113. 
Cerebral  paralysis,  spastic,   170. 
•Childhood,  122. 
Chloral  hydrate,  107,  217,  218,  241. 
Chloralism,  249. 
Cliloroformism,  249. 
Cholera,  232. 

Chorea  chron.  progi'essiya,  224. 
Choreic  psychoses,  224. 
Chorea  sydenhamii,  224. 
Circiilar  psychosis,   117,   136,  196. 

continuing.  196. 

diagnosis,   198. 

etiology,  198. 

intermittent,  196. 

prognosis.  199. 

results,  198. 

treatment.  199. 
Circumspection,  59. 
Claustrophobia,  56. 
Climacteric,  125,  137. 

in  men,  125,  273. 
Clinotherapy,  155. 
Clysters,  157. 
Cocainism,  248. 
Codeinum  phosphor.,   154. 
Collapse,   157. 

delirium,  179. 
Collecting,  propensity  for,  75. 
Colonization,   159. 
Coma,  67. 

Commitment  to  institution,  295. 
Compulsion  means,  158, 
Concepts,  imperatiye.  26,  199,  200. 

202. 
Confabulation,  42. 
Confusion,  59. 

and  word  deafness,  80. 

aphasic,  276. 

demented,  60,  139. 

hallucinatory,  59,  177. 

in  the  emotions,  60. 

maniacal.  59.  181,  184. 

paraphasic,  60. 


Confusion,  thefts  in,  70. 
Consciousness,  4. 

alternating.  63. 

disturbances,  59. 

double,  63. 
Constipation,  103. 
Coprolalia,  79. 
Coprophagi,  48. 
Corpus  callosum,  172. 
Countenance,  disturbances,  77. 

expression  of,  83. 
Course  of  psychoses,  133. 
Cranial  deformities,  86,  90,  92,  95. 
Crania  of  the  idiots:   pathological 

anatomy,  172. 
Cranio-facial  angle,  86. 

measurements,  85. 
Cranium  of  the  cretin,  228. 
Cretinism,  227. 

sporadic,  225. 
Cretinous,  228. 
Cretins,  atypical,  228. 

t^'pical,  228. 
Cure  of  a  patient,  153. 
Cutaneous  hallucinations,  13. 
Cyanosis  of  the  skin,  107,  192. 
CyclotliATuia,   196. 
Cynanthropia,  14,  29. 

Darwin's  pointed  ear.  94. 
Death,  141. 
Decubitus,  108,  158. 
acutissimus,  108. 
Defects,  yisual,  97. 
Defiling.  104,  158. 
Degenerates,   99,   121. 
Degeneration,  84. 

stigmata     of      (somatic     symp- 
toms), 85. 
Delire  d'emblee,  204. 
Delirium  acutum,  134,  179, 
conyergens,  30,  208. 
diyergens,  28.  29. 
hallucinatorium,  44,  136, 
actiye,   175, 
diagnosis,  178. 
etiology-,  177. 
outbreak,  177. 
passiye,  175. 
results,  178, 
s^nnptomatolngy,  176. 
treatment,  179. 
metabolicum,  22,  33. 
of  occupation,  238. 
palingnosticum.  22,  33. 
tremens.  239. 
Delusional  stiipor,  64. 
Delusions,  27. 


Index. 


305 


Delusions,  combined,  34. 
depressive,  28. 
diagnosis  of.  36. 
expansive.  27. 

of  attention,  30,  31,  203,  24a. 
of  detraction,  245. 
of  jealousy,  31.  209,  220,  242. 
of  negation,  32,  77,   191- 
of  recognition,  33. 
of    transgression,    28,    189,    IJl, 

214. 
paranoic,  30,  142. 
prognosis,  38. 
relation,  30,  204. 
residuary,  35,  203. 
retroactive  formation,  42. 
signs  of,  38. 
systematized,  31,  34. 
thefts,  70. 
treatment,  38. 
Dementia  acuta,  179,  211. 
agitata,  139. 
apathica,  140. 
diagnosis,  212. 
etiology,  212. 
paralytica,   251,    see   progressive 

paralysis,  paresis, 
paralytica  traumatica,  2/9. 
paranoides,  207. 
praecox,   123,  124,  140,  207. 
precocious,  102.  ,    ,oa    141 

secundaria  or  terminal,  139,  i-ii, 

145,  178,  185,  194. 
senilis,  126,  267,  208. 
treatment,  213. 
Demonomania,  209. 
Demonomelancholia,  29. 
Dental  obsession,  58. 
Dermograpliia,  107. 
Destruction,  rage  for,  158. 
Diabetes,  230. 
Diabetic  psychoses,  230. 
Diagnosis  of  mental  diseases,  14o. 
Digftalis,  217,  218. 
Dionin,  155. 
Diphtheria,  232. 
Dipsomania,  46. 
Disease,  feeling  of,  50. 

perception  of,  50. 
Dismissal  from  institution,  196. 
Disorientation,  59. 
Dispasmus  cercbralis,  170. 
Dissimulation,  148. 
Diuretin,  241. 
Division  of  psychoses,  160. 
Dolichocephalic,   86. 
Dolichocephalus.  90,  95. 
Doubt,  pathological,  200. 


Dream  states,  63. 
Duboisin,  180,  256. 
Duration  of  psychoses,  133. 
Dysarthria  literalis,  80. 

syllabaris,  80. 
Dysentery,  232. 
Dysphrasia  vosana,  78. 
Dysthymia  neuralgica,  63. 

Ear,  varieties,  93. 

Echo  speech,  79. 

Ecstasy,  65. 

Ego  phony,  81. 

Egotism,  51,  164. 

Elbow  reflex,  105. 

Emotion,  55. 

Emotivity,  55. 

Encephalitis  htEmorrhagica,  2M. 

Encephalopathia     saturnina,     2o0, 

266. 
Endogenous  psychoses,  225. 
Entoptic  phenomena,  7. 
Entotic  phenomena,  7. 
Enuresis,  103. 
Environment,  120. 
I  Epidemics  and  insanity,  114.  ^ 
Epilepsy  and  iodiotism,  170,  1(3. 
and  trauma,  279. 
psychical,  62. 
Epileptic  seizures,  239. 
imperative  concepts,  202. 
psychoses,  213. 
chronic,  217. 
path,  anatomy,  218. 
treatment,  218. 
Epileptiform  seizures,  260. 
Epileptoid  seizures,  260. 
Equivalents,  epileptic.  215. 
Erethism  mercurialis.  250. 
Ergotin  in  mania,  187. 
Ergotism,  233. 
Erysipelas,  232. 
Ervthrophobia,  200.  _ 
Esophageal  sound,  157. 
Ether,  158. 
Etheromania,  249. 
Ethical  defects,  217. 
Etiolog>'  of  mental  diseases,  113. 
Examination  of  insane,  282. 
Exhaustion,  141. 
Exhaustion  deliria,  240. 

psychoses,  132. 
Exhibitionism,  49. 
Extra-social,   173. 
Eyes,  anomalies,  94. 
distortion  of,  94. 
pupils,    100,    see    myosis,    my- 
driasis. 


306 


Index. 


Fabulating,  42. 
Fatigue,  feeling  of,  48. 
Febrile  diseases,  137. 
Feces,  104. 

smearing  with,  158. 
Feelings,  diminution  of,  48. 

of  disease,  50. 

heightening  of,  45. 

of  judgment,  51. 

ordinary,  50. 

pathological,  50. 

sensory,  45. 
Fetichism,  77. 
Fever  delirium,  178,  231. 
First-born,  171. 
Fixed  ideas,  35,  205. 
Flexibilitas  cerea,  64. 
Focal  disease,  267. 
Folie  a  deux,  128. 

communiquee,  128. 

gemellaire,  128. 
Frame  of  mind,  4,  55. 
Frontal  arc,  91. 
Functional  psychoses,  175. 

path,  anatomy,  213. 

course,  135. 

Gastric  juice,  192. 
Gastro-enteric  tract,  130. 
Gaz  pauvre   (poor  gas),  249. 
Gout,  230. 
Greediness,  45. 

Guide   for   examination   of   insane. 
282. 

Hair,  development  of,  99. 

trophic  disturbances,   108. 
Hallucinations.    10,    19,    143,    176, 
180,   207,   214,   215,   219,   220, 
221,  255,  270. 

alcoholic,  237. 

antagonistic.  17. 

auditory,  11,  30,  143. 

coenesthetic,  14. 

dedoublee,  17. 

dissimulation  of,  22. 

hearing,  237. 

hji^nagogic,  20,  237. 

in  hysteria  and  epilepsy,  20. 

in  idiots,  20. 

in  persons  of  normal  mind,  20. 

kinesthetic,  14. 

occurrence,  19. 

of  sensation,  13. 

of  the  smell,  12. 

of  the  taste,  12. 

of  vision.  30. 

physiological  patholog;^'  of.  18. 


Hallucinations,  prognosis,  23. 
psychic,  22. 
puzzling,  238. 
residuary,  21. 
secondary,  17. 
significance  for  action,  23. 
treatment,  23. 
unilateral,  16. 
voluntarise,  16. 

with  consciousness  of  deception. 
21. 
Hallucinosis,  acute,  of  the  drinker, 

241. 
Headache,  101. 
Heart  affections,  109,  130. 
muscles,  change  of,  109. 
Heat  stroke,  280. 
Hebephrenia,  122,  190. 
Hedonal,  156. 
Help  classes,  174. 

schools,  174. 
Hematoporphyrin,  156. 
Hemierania,  see  migraine,  102. 
Hemorrhages,  107. 
Heredity,  115. 
collateral,   116. 
coneeptional,  116. 
cumulative,  115,  117. 
dissimilar,  115. 
double,  115. 
homochronous,  115. 
indirect,  116. 
in  insane,  119,  120. 
mediate,  115. 
progressive,  115. 
regressive,  115. 
transformed,  115,  116. 
uterine,  119. 
Heroin,  155. 
Heterotopia    of    the    grav    matter, 

172. 
Hippocratic  coimtenance,  106. 
Hippus,  101. 
Hutchinson's  teeth,  98. 
Hydrocephalus,  89,  172. 
Hydrophobia,  48. 
Hyperhidrosis,  107. 
Hvperkinesis,  72. 
Hypermnesia.  40,  162,  184. 
Hyperorthognathous,   87. 
Hyperprosexia.  61. 
Hypertonia,  102. 
Hyphidrosis,  107. 

Hypnagogic  hallucinations,  20,  237. 
Hypnotism,  65. 

Hvpochondric     hallucinations,     14, 
148. 
delusions,  20,  190. 


Index. 


307 


Hypochondric  delusions,  suicide  in, 
142. 

sensations,  0. 
Hypomania,  1S2. 
Hyponiehinoholia,  1S7. 
Hypotonia,  102. 
Hypsophobia,  5G. 
Hysteria,  hallucinations  in,  20. 

imperative  concepts  in,  202. 

psychoses  of,  76,  219. 
Hysterical  symptoms,  221,  222. 
Hystero-epilepsy,  221. 

Ideas,  flight  of,  26. 
Idiocy,  167. 

acquired  form,  167. 

congenital  form,  107. 

familiar  amaurotic,  171. 

symptomatology-,   168. 
Idiotia  myxedematosa,  225. 
Idiotisni,  161. 
Illusion,  15,  176. 
Imbeciles,  active,  161. 

anergetic,  161. 
Imbecility,  161. 

acquired,  139. 

congenital,  161. 

symptoms,  162. 
Imperative  concepts,  199. 
Impression,  capability  of,  25. 
Imprisonment,  132. 
Incest,  50. 
Incurability,  150. 

of  mental  diseases,  l;)9. 
Indican,  230. 

Induced  insanity,  128,  129. 
Infantilism,  myxedematous,  226. 
Infection,  psychic,  128. 
Infection  psychoses,  231. 
Infinitive  speech,  80. 
Influenza,  232. 
Inheritors,  72,  118,  149. 
Initial  deliria,  231. 
Insomnia,  155,  180. 
Instinct,  5. 

Instinctive  actions,  71. 
Institutions,  commitment  to  these, 
295. 

in  New  York,  295. 

number     of    mentally     diseased, 
113. 

treatment,  151. 
Intestine,    auto-intoxication    from, 

130,  230. 
Intoxication,  apoplectic,  235. 
convulsive,  235. 
pathological,  236. 


Introduction,  1,  7. 
Iodoform  psychoses,  250. 
Ischuria,  103. 

paradoxa,  103. 
Island-formed  recollection,  215. 

Judgment,  3. 

diminution  of,  51. 
feelings  of,  3,  51. 
heightening  of,  51. 
pathological  inversion  of,  52. 

Katamnesia,  64. 

Katatonia,  65,  102,  123,  207. 

Kephalones,  89. 

Kinesthetic  hallucinations,   14. 

Kleptomania,  54,  165. 

Klinocephalus,  90. 

Knife  anxiety,  57. 

Korsakoff's  disease,  42,  232,  237. 

Lactation,  period  of,  127. 
Leprosy,  232. 
Leptocephalus,  90,  95. 
Lesbian  love,  49. 
Little's  paralysis,   171. 
Liver  diseases,  230. 
Logorrhea,  SO. 
Lucid  interval,  135. 
Lumbar  punction,  174. 
Lycanthropia,  14,  29. 

Macrocephalus,  88,  95. 
Macropsia,  10. 
ilagnan's  symptom,  248. 
IMaidism,  234. 
Malingerer,  148. 
j\Ialum  perforans,  108. 
Mania,  180. 

ambitiosa,  184. 

cardiaca,  185. 

diagnosis,  185. 

etiology',  184. 

gravis,  182. 

of  doubt  with  fear  of  touch,  57. 

periodica,   1S2,  136. 

prognosis,  186. 

recurrens,  182. 

results,  185. 

symptomatolog;^',   183. 

transitoria,   134. 

treatment,   186. 
J\Ianic-depressive      insanity,       138, 

196. 
Manners.  75. 
]\lasochism,  50. 
Maternal  transmissibility,  116. 


308 


Index. 


^Megalomania,  30. 
Megalomaniacal  ideas,  14:3,  181. 
Megalophthalmus,  96. 
Melancholia.  179,  187. 

activa  and  agitata,  189. 

alcoholistica,  24:1. 

duration,  193. 

etiology,  193. 

generalis,   189. 

hypochondvica,  188. 

moralis,  188. 

outbreak,  193. 

paranoides.  207. 

passiva,  189,  19-5. 

periodical,  136,  193. 

prognosis,   194. 

remittens.  193. 

results,  194. 

simplex,  187. 

SAauptomatolog^*',  190. 

treatment.  195. 

typica,  188. 

with  suicide,  142,  152. 
Melancholic  delusion.  28.   190. 

suicide  in,  128,  192. 
Memorv.    disturbances   of,    40,    45, 

162,  168. 
Menstrual  psychoses.  136. 
Menstruation.  Ill,  136,  192. 
]\leutal  disturbances,  acute,  134. 

chronic.  136. 

periodically  progressive,  136. 

transitory.  133. 
ilercurial  intoxication,  250. 
Mesocephalic,  87. 
Mesognathous,  87. 
Metamorphosis,   delusion  of,   29. 
Microcephalus,  89,  95. 

Aztec  type,  89. 
[Miciogyria,  172. 
Micromania,  28,  191. 
Micromaniacs.  81. 
ilicrophthalmus,  94,  96. 
Micropsia.  10. 
Migraine.  102. 
Mirror  speech,  82. 

writing.  82. 
Mongol  cranium,  172. 
Monomania.  165. 
Monophobia.  56. 
Moral  insanity,  52. 

epileptic,  217. 
^lurder.  monomania  for.  54. 
Morally  insane,  thefts,  76. 
Morel's  ear,  93. 
Moria.  181. 

Morphia.  154.  155,  195,  241. 
Morphinism,  245. 


Motility,  disturbances  of,  102. 

Mouse  odor,  107. 

Mucous  membranes  reflexes,  106. 

Miu'der,  voluptuous,  50. 

Muscles,   changes   of  the  tone,   see 

stupor,  102. 
Muscle  sense,  hallucinations  of,  13. 
Mutacism,  77,  123. 
ilutism,  deaf,  78. 

hvsterical.  77. 
Mydriasis.   100,  101. 
Myosis,  100. 
Mysophobia,  57. 
Myxedema  of  adults,  227. 

infantile,  225. 

operati^Tim,  227. 


arcism,  47. 

arcolepsy,  61,  220,  252. 
epileptic.  215. 
ecrophilism,  50. 
egativism,  33,  73,  123,  191. 
eologism,  78. 
euralgias,  129. 
and  delusions,  36. 
euralgiform    pains    in    hypochon- 

dric    and    hysteric    psychoses, 

102. 
euritis  multiple,  232,  233. 
with  progi-essiye  paralysis,  258. 
icotinism,  249. 
itroglyccrine.  203. 
ourishing  clysters,  157. 
ourishment,  liquid,  156,  157. 
lack  of.  157. 

refusal  of,  33,  48,  110,  156. 
yktophobia,  56. 
ymphomania,  47. 


Old  age,  125. 
Oleum  camphorat..  158. 
Onanism,  47,  131.' 
Onomatomania,  79,  201. 
Operations  and  psychoses,  223. 
Opium.  154,  241.   ' 

abuse  of.  249. 

treatment  of  melancholia,  195. 
Opposition,  73. 
Organic  psychoses,  251. 
Orientation,  59. 
Othematoma,  107,  108. 
Outbreak  of  psychoses,   133. 
Oxide  of  morphine,  247. 
Oxycephalus,  90,  95. 

Pachymeningitic  psychoses,  273. 
Palate,  hard.  97. 
Paracephalus,  90. 


Index. 


309 


Paradoxia  sexualis,  47,  53. 

Pararhotacism,  80. 

Para<Trnphia,  74,  257. 

Parasigmatism,  80. 

ParaUleliyde  broath,  100,  15G. 

Paraspasmus  cerebralis,  170. 

Paralexia,  74. 

Parturition,  126. 

Paralysis  agitans,  273. 

Patellar  reflex,  104,  105. 

Paralysis  progi-essiva,  paresis,  251- 

Paternal  transmissibility,   116. 

268. 

Pathological    anatomy    of    mental 

agitated  form,  254. 

diseases,  144. 

and  chorea  chron.  progr.,  224. 

Pederasty,  49. 

and  lymphocytosis,  200. 

Pellagra,"^  234. 

and  suicide,   144. 

Peptonuria  in  paresis.  111. 

ascending  form,  255. 

Percentage  of  heredity,   119. 

circular  form,  254. 

Perception  of  disease,  50. 

classical  form,  254. 

Periodic    psychosis,    117,    130,    150, 

conjugal  form,  2(52. 

178,  182,  207. 

course,  135,  263. 

Persecuted  persecutors,  32. 

demented  form,  251. 

Persecution,  delusion  of,  30. 

depressive  form,  254. 

melancholic  delusion  of,  28. 

diagnosis,  265. 

paranoic  delusion  of,  30. 

duration,  263. 

Perseveration,  39,  79,  80. 

etiologA%  261. 

Personality,  duplication  of,  70. 

in  children,  173,  262. 

Persons,  non-recognition  of,  15. 

path  logical  anatomy,  264. 

Pertussis,  232. 

somatic  symptoms,  258. 

Phenacetin,  154. 

symptomatologj',  255. 

Phobias,  56. 

treatment,  268. 

Photography  of  thought,  11. 

Paralytic  attacks,  253,  260,  271. 

Phrenolepsia  erotematica,  201. 

disturbances  of  the  speech,  256. 

Piarhemia,   239. 

Paramimia,  75. 

Pica,  48. 

Paramnesia,  22,  41. 

Plagiocephalus,  90,  95. 

Paranoia,  199. 

Platycephalus,  90,  95. 

combinatoria,  204. 

Polyglots,  163. 

confabulans,  207. 

Porencephalus,  172. 

diagnosis,  210. 

Poriomania,  217. 

erotica,  209. 

Post-epileptic  insanity,  214. 

etiolog;^^  210. 

Poverty,  delusion  of,  191. 

hallucinatoria  acuta,  205. 

Precordial  anxiety,   106,   192. 

hallucinatoria  alcoholistica,  241. 

Predisposing  factors,  115. 

hypochondrica,  206. 

Pre-epileptic  insanity,  214. 

katatonica,  207. 

Pregnane  J',   126. 

outbreak,  210. 

Prison  psychoses,  132. 

periodica,  207. 

Prognathoiis,  87. 

primitiva,  206. 

Prognosis  of  mental  diseases,   14D. 

querulant,   209. 

Prophylaxis  of  psychoses,  150. 

religiosa,  209. 

Pseudodipsomania,  46. 

rudimentaria,   199. 

Pseudologia  phantastica,  43. 

secundaria,   139. 

Pseudomicrocephalus.   172. 

simplex,  acuta,  203. 

Pseudoparcsis  alcoholica.  243. 

simplex,  chronica,  204,  206. 

Psychic  causes  of  insanity,  128. 

stuporosa,  208. 

infection,  128. 

symptomatolog;y,    207. 

treatment,   159. 

treatment.  2]o! 

Psychometry,  26,  164. 

typica,  203. 

Psychoses,  functional,   175. 

Paranoic    delusions,    30,    142,    194, 

infectious,  231. 

208,  214,  241. 

intoxication,  225. 

Paraphasia,  74,  80. 

organic,  251. 

Paraphrasia  vesana,   177. 

Puberty,   122,   190,  222. 

Parapraxia,  75. 

Puerperal  psychoses,  127. 

310 


Index. 


Puerperium,   126. 
Pulse,  changes  of,  109. 
Pupils    disappearance   of   reaction, 
100. 

inequalities,  significance  of,  100 

paradoxical  reaction,  101,  259. 

reaction,  100. 

reaction,  inverse,  259. 

rigidity,    reflex,    101,    222,    252, 
259. 
Puzzle  hallucinations,  238. 
Pyromania,  54. 

Querulants,  32,  209. 

Railway  brain,  277. 

Raptus  melancholicus,   134,   189. 

Rash,  156. 

Raving,  anxious,  56,  68. 

maniacal,  26,  68,  181. 
Recollection, 

deception  of,  34. 

falsifications  of,  41,  42. 

identifying,  43. 

insular,  215. 
Recoveries,  with  defects,  138. 
Recovery,  138. 

incomplete,  138. 
Reflex  actions,  70. 

hallucinations,  17. 
Refusal  of  nourishment,  156. 
Relapses,  149. 

Reproduction,  power  of,  162,  16S. 
Residuary  delusions,  35,  203. 
Rest  in  bed,  155. 
Results  of  the  psychoses,   138. 
Rheumatism,  articular,  232. 
Rhinhematoma,  108. 

Sadism,  50. 

Salicylate  intoxication,  249. 

Saliva,  secretion  of,  107. 

Salt  infusions,  157,  247. 

Saturnism,  250. 

Satyriasis,  47. 

Scopolaminum  hydrobr.,  154,  156. 

Secessus  involuntarii,  104. 

Secondary  hallucinations,  17. 

Secretions,  anomalies  of,  106. 

Self-accusation,  28. 

-consciousness,  4. 

disturbances  of,  69. 
Senile  dementia,  268. 
Sensations  after,  8. 
Sense     deceptions,     see    hallucina- 
tions, illusions,  visions,  10. 
Sense  impression,  1,  7. 

hypochondric,  9. 


Sense,  hysterical,  220. 

secondary,  8. 
Sense  perception,  anesthesia,  24. 

disturbances  of,  7. 

hyperesthesia     and     paresthesia, 
"7,  8. 

hypesthesia,  24. 

hypochondric,  9. 

hysterical,  220. 

impression,  1,  7. 

in  idiots,  168. 

secondary,  8. 
Sensibility,  disturbances  of,  101. 
Septicemic  deliria,  240. 
Sexual    apparatus,    hallucinations, 
14. 

female,  as  cause  of  insanity,  130. 

male,  as  cause  of  insanty,  131. 
Sexual  feelings,  221. 

diminution,  48. 

heightening  of,  47,  183. 

perversity,  48. 

reflex,  106. 

sensation,  'contrary,  48. 
Shipwrecked,  131. 
Shock,  278. 
Simulation,  147,  148. 
Sitophobia,    see    nutrition   refusal, 

110. 
Skin,  abnormalities,  98. 

reflexes,  105. 
Skull,  deviations,  88. 
Sleep,  61. 

Snout  cramp,  65,  66. 
Sodomy,  50. 
Somatic  causes,  129. 
Somnambulism,  63. 
Somnolentia,  61,  67. 
Sopor,  67. 

Sound  associations,  184. 
Spasms,  muscular,  102. 
Speech,  disturbances  of,  77. 

internal,  13. 

of  idiots,  169. 

paralytic,  256. 
vSpeechlessness,  77,  78. 
Sphenoccphalus,  90,  95. 
Sphymography,  110,  198,  260. 
Spiritus  vini  rectifieatus,  195. 
Stahl's  ear,  94. 
Stammering,     see     dysarthria     lit- 

eralis,  80. 
Stereotypes,   73,   123. 
Stigmata  of  degeneration,  84, 
Stomach  tube,  157. 
Stramonium,  24. 

intoxication,  249. 
Strychnine,  241. 


Index. 


311 


stupor,  03,  73,  110. 

aiicrjrie,  (17. 

anxious,  30,  64,  212. 

delusional,  (54. 

hypotonic,  67,  111,  212. 

katatonic,  65,  111. 

maniacal,  65. 

negative,  65. 
Stuttering,    see    dysarthria    sylla- 

baris,  80. 
Subacute  psychoses,  135. 
Suggestibility.  219,  222. 
Suicide,  141,"  158. 

indirect,  144. 
Sulfonal,  155. 

intoxication,   155. 
Sunstroke,  280. 
Sweat  secretion,  107. 
Syllable  stumbling,  81. 
Symbolization,  22. 
Syphilis,  131,  262,  266,  268,  273. 

hereditary,  171,  262,  266. 
Syphilitic  psychoses,  273. 
Syphilophobia,  131. 

Tabo-paresis,  255. 
Teeth,  aonormalities,  98. 

anxiety,  5S. 

deformities  of,  98. 

trophic  disturbances,  109. 
Temperature,    inverted    type,    112, 
223. 

of  body,  112,  223,  239. 

sense,  hallucinations  of,  13. 
Tendon  reflexes,  104. 
Tetronal,  150. 
Thefts,  75. 
Thyroid  gland  psychoses,  225. 

preparations,  154,  174,  226. 
Tic  actions,  72. 

-like  thefts,  76. 
Tongue  delirivim,  80,  177. 
Torus  palatinus,  98. 
Trance,  63,  235. 
Transformed  insanity,  129. 
Transitory     mental     disturbances, 

133. 
Trauma,  141,  277. 
Treatment  of  mental  diseases,  150. 
Tribadism,  49. 
Triceps  tendon  reflex,  105. 


Trigonocephalus,  90,  95. 
Trional,  154,  156. 

intoxication,  249. 
Trochoccphalus,  90,  95. 
Trophic  disturbances,  106. 
Tropical  insanity,  132. 
Tuberculosis,  109,  129,  141. 
Tumultus  sermonis,  80. 
Twilight   states,    02,    63,    75,    143, 

214,  220.'235. 
Twins,  insanity  in,  128. 
Typhoid  fever,  232. 

Uncleanliness,  104. 

Unrest,  remedies  against,  154 

Uremia,  230,  266. 

Urethane,   156. 

Urine,  albumen  in.  111,  239. 

in  alcoholists,  239. 

in  circular  psychosis,  198. 

in  melancholia,  192. 

in  paresis,  260. 

in  refusal  of  nutrition,  111. 

phosphoric  acid  contents.   111. 

sugar  in.  111. 

Vagabonds,  53. 

Vagus  nerve,  paralysis  of,  141. 

Variola,  232. 

Vasomotor  nerves,  106,  192. 

disturbances,  106. 
Verbigeration,  79,  177. 
Visceral  reflexes,  100. 
Visual  defects,  96. 
Vision,  hallucinations  of,  15. 
Voice,  tone  of,  81. 

Weakmindedness,  acquired,  140. 

Weight  of  body.  111,  112,  184,  259. 

Wet  packs,  155. 

Wildermuth's  ear,  94. 

Will,  5. 

Willis,  dictum  of,  147. 

Word  deafness,  80. 

Writing,  change  of,  81,  257. 

disturbances,  81. 

obsession  for,  81. 

Zinciun  aceticum,  241. 
Zoopsy,  10. 


